Department of Veterans Affairs 

Office of Inspector General 

Office of Healthcare Inspections
 

Report No. 11-00024-152 

Combined Assessment Program
 

Review of the
 

Wilmington VA Medical Center
 

Wilmington, Delaware
 

April 27, 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 Wilmington VA Medical Center, Wilmington, DE 

Glossary 

C&P credentialing and privileging 

CAP Combined Assessment Program 

CBOC community based outpatient clinic 

CHF congestive heart failure 

CLC community living center 

COC coordination of care 

CWAD Crises, Warnings, Allergies, and/or Adverse 

Reactions 

ECMS Executive Committee of the Medical Staff 

EOC environment of care 

facility Wilmington VA Medical Center 

FY fiscal year 

ICU intensive care unit 

JC Joint Commission 

MDRO multidrug-resistant organisms 

MEC Medical Executive Committee 

OIG Office of Inspector General 

OSHA Occupational Safety and Health Administration 

PI performance improvement 

QM quality management 

RCA root cause analysis 

VHA Veterans Health Administration 

VISN Veterans Integrated Service Network 

VA OIG Office of Healthcare Inspections 
CAP Review of the Wilmington VA Medical Center, Wilmington, DE 

Table of Contents
 

Page
 

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

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

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

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

Reported Accomplishments...................................................................................... 2
 

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

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

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

QM..................................................................................................................... 3
 

Management of MDRO...................................................................................... 4
 

Management of Test Results............................................................................. 5
 

COC .................................................................................................................. 5
 

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

Medication Management ................................................................................... 7
 

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

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

Appendixes 

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

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

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

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

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

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

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

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

Review of the Wilmington VA Medical Center, Wilmington, DE 

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 

February 7, 2011. 

Review Results: The review covered 

seven activities. We made no 

recommendations in the following 

activities: 

	 Medication Management 

	 Physician Credentialing and 

Privileging 

The facility’s reported accomplishments 

were the receipt of a Silver Cornerstone 

Award for patient safety and the 

Hospice Initiative for Homeless and 

Rural Veterans. 

Recommendations: We made 

recommendations in the following five 

activities: 

Environment of Care: Complete and 

document N95 respirator fit testing 

annually. Strengthen processes to 

ensure medication security. 

Quality Management: Implement a plan 

to address the delivery of care to 

patients held in temporary bed locations. 

Strengthen processes to ensure that: 

 Quality management-related 

committees develop specific action 

plans when problems are identified 

and track action items to completion. 

 Analysis of data related to 

resuscitation episodes includes all 

required elements. 

 All required components are included 

in medical record reviews and that 

results are reported quarterly. 

Management of Multidrug-Resistant 

Organisms: Provide infection prevention 

strategies education to patients infected 

or colonized with multidrug-resistant 

organisms and their families, and 

document it. 

Management of Test Results: 

Consistently communicate normal test 

results to patients within the specified 

timeframe. 

Coordination of Care: Provide and 

document advance directive notification, 

use required progress note titles to 

document advance care planning, link 

note titles to electronic medical record 

postings, and ensure discharge 

instructions include appropriate diet 

orders. 

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 Wilmington VA Medical Center, Wilmington, DE 

Objectives and Scope
 

Objectives
 

Scope
 

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

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

services. The objectives of the CAP review are to: 

	 Conduct recurring evaluations of selected health care 

facility operations, focusing on patient care administration 

and QM. 

	 Provide crime awareness briefings to increase employee 

understanding of the potential for program fraud and the 

requirement to refer suspected criminal activity to the 

OIG. 

We reviewed selected clinical and administrative activities to 

evaluate the effectiveness of patient care administration and 

QM. Patient care administration is the process of planning 

and delivering patient care. QM is the process of monitoring 

the quality of care to identify and correct harmful and 

potentially harmful practices and conditions. 

In performing the review, we inspected selected areas, 

interviewed managers and employees, and reviewed clinical 

and administrative records. The review covered the 

following seven activities: 

	 COC 

	 EOC 

	 Management of MDRO 

	 Management of Test Results 

	 Medication Management 

	 Physician C&P 

	 QM 

The review covered facility operations for FY 2010 and 

FY 2011 through February 11, 2011, and was done in 

accordance with OIG standard operating procedures for CAP 

reviews. We also followed up on selected recommendations 

from our prior CAP review of the facility (Combined 

Assessment Program Review of the Wilmington VA Medical 

Center, Wilmington, Delaware, Report No. 08-01428-11, 

VA OIG Office of Healthcare Inspections 1 
CAP Review of the Wilmington VA Medical Center, Wilmington, DE 

October 21, 2008). The facility had corrected all prior 

findings. (See Appendix B for further details.) 

During this review, we also presented crime awareness 

briefings for 201 employees. These briefings covered 

procedures for reporting suspected criminal activity to the 

OIG and included case-specific examples illustrating 

procurement fraud, conflicts of interest, and bribery. 

In this report, we make recommendations for improvement. 

Recommendations pertain to issues that are significant 

enough to be monitored by the OIG until corrective actions 

are implemented. 

Reported Accomplishments
 Silver Cornerstone 

Award 

Hospice Initiative 

for Homeless and 

Rural Veterans 

The facility received a Silver Cornerstone Award in 2010 

from the National Center for Patient Safety for the timeliness 

of and strength of action plans for RCAs.1 

The Hospice Initiative for Homeless and Rural Veterans 

partnership focuses on outreach to homeless and rural 

veterans. Partners include the Delaware End of Life 

Coalition, Delaware Hospice, Delaware Veterans Home, the 

facility, and state veterans service officers. The program is a 

national model and provides education about veterans’ 

special needs at the end of life to first responders (police 

officers, paramedics, and firefighters) and community 

hospices. 

Results 

Review Activities With Recommendations 

EOC	 The purpose of this review was to determine whether the 

facility maintained a safe and clean health care environment 

in accordance with applicable requirements. 

We inspected the emergency department, a medical/surgical 

unit, an ICU, a dialysis unit, outpatient clinical areas, the 

dental clinic, the CLC, and the radiology department. The 

facility maintained a generally clean and safe environment. 

However, we identified the following conditions that needed 

improvement. 

1 An RCA is a tool or method used to determine why a problem happened and what can be done to prevent the 

problem from happening again. 

VA OIG Office of Healthcare Inspections 2 
CAP Review of the Wilmington VA Medical Center, Wilmington, DE 

Infection Control. If facilities use N952 respirators, OSHA 

requires that designated employees are fit tested annually. 

We reviewed 20 employee training records and determined 

that 3 designated employees had the required annual fit 

testing. 

Medication Security. JC standards require all medications to 

be secured from access by unauthorized persons. We found 

that only four of the seven clinical units inspected had 

secured medication storage. 

Recommendations	 1. We recommended that annual N95 respirator fit testing 

be completed and documented. 

2. We recommended that processes be strengthened to 

ensure that medication security is maintained. 

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. 

Action Plan Documentation. The JC requires facilities to 

collect and analyze data on important quality measures and 

to take action based on that analysis. Meeting minutes from 

multiple QM-related committees did not document specific 

action plans when problems were identified. For example, 

the facility identified a problem with the overhead paging 

system but did not identify a specific action plan to address 

the problem. 

Resuscitation and Its Outcomes. VHA requires that facilities 

measure performance of relevant processes in responding to 

resuscitation episodes.3 We did not find evidence that the 

facility analyzed resuscitation data related to errors or 

deficiencies in technique, malfunctioning equipment, and 

delays in initiating cardiopulmonary resuscitation. 

2 An N95 respirator mask provides respiratory protection through a tight facial seal and 95 percent filter efficiency.
 

Although the “N” means “not resistant to oil,” the respirators are fluid resistant.

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

Cardiopulmonary Resuscitation Committees, October 17, 2008.
 

VA OIG Office of Healthcare Inspections 3 
CAP Review of the Wilmington VA Medical Center, Wilmington, DE 

Recommendations 

Management of 

MDRO 

Medical Record Review. VHA requires facilities to conduct 

medical record reviews that include specific areas of review 

and to report the results quarterly.4 While medical record 

quality reviews had been completed, we found that they did 

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

facility did not monitor documentation of an outpatient visit 

when one existed in the outpatient scheduling program. We 

also found that results were reported in only 3 of the 

4 required quarters. 

Systems Redesign/Patient Flow. The JC requires facilities to 

have a plan to address the delivery of care to patients who 

might be held in temporary bed locations. We found that the 

facility did not have the required plan in place. 

3. We recommended that processes be strengthened to 

ensure that QM-related committees develop specific action 

plans when problems are identified and track action items to 

completion. 

4. We recommended that processes be strengthened to 

ensure that analysis of data related to resuscitation episodes 

includes all required elements. 

5. We recommended that processes be strengthened to 

ensure that all required medical record review components 

are included and that results are reported quarterly. 

6. We recommended that the facility implement a plan to 

address the delivery of care to patients held in temporary 

bed locations. 

The purpose of this review was to evaluate whether the 

facility had developed a safe and effective program to reduce 

the incidence of MDRO in its patient population in 

accordance with applicable requirements. 

We inspected the general medicine (4E) unit, an ICU, the 

hospice unit, and the CLC, and we interviewed eight 

employees. We identified no deficits in either the inspections 

or staff interviews. However, we identified the following area 

that needed improvement. 

Patient/Family Education. The JC requires that patients 

infected or colonized5 with MDRO and their families receive 

4 VHA Handbook 1907.01, Health Information Management and Health Records, August 25, 2006. 5 Colonization is the presence of bacteria in the body without causing clinical infection. 

VA OIG Office of Healthcare Inspections 4 
CAP Review of the Wilmington VA Medical Center, Wilmington, DE 

education on infection prevention strategies, such as hand 

washing and the proper use of personal protective 

equipment. We reviewed 11 medical records and found that 

only 3 had documented evidence of MDRO education. 

Recommendation	 7. We recommended that infection prevention strategies 

education be provided to patients infected or colonized with 

MDRO and their families and be documented. 

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

Test Results review that identified improvement opportunities related to 

documentation of notification of abnormal test results and 

follow-up actions taken.6 

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

reviewed medical records. We identified the following area 

that needed improvement. 

Communication of Normal Results. VHA requires facilities to 

communicate normal results to patients no later than 

14 calendar days from the date that the results were 

available to the ordering provider.7 We reviewed the medical 

records of 20 patients who had normal results and found that 

only 14 records contained documented evidence that the 

facility had communicated the results to the patients. Of the 

results not communicated to the patients, five were radiology 

results, and one was a laboratory result. 

Recommendation	 8. We recommended that normal test results be 

consistently communicated to patients within the specified 

timeframe. 

COC	 The purpose of this review was to evaluate whether the 

facility managed advance care planning, advance directives, 

and discharges in accordance with applicable requirements. 

We reviewed patients’ medical records for evidence of 

advance care planning, advance directives, and discharge 

instructions. We identified the following areas that needed 

improvement. 

Advance Directive Notification. VHA requires that patients 

be given written notification at each admission stating their 

right to accept or refuse medical treatment, to designate a 

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

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

VA OIG Office of Healthcare Inspections 5 
CAP Review of the Wilmington VA Medical Center, Wilmington, DE 

Health Care Agent, and to document their treatment 

preferences in an advance directive.8 Our review of medical 

records found that facility staff documented notification for 

only 2 of 10 patients. 

Advance Care Planning Progress Note Management. VHA 

requires that staff use specific progress note titles when 

documenting advance care planning discussions with 

patients and link these notes to the CWAD posting9 in the 

electronic medical record.10 We found that local policy 

correctly referenced the three required note titles. However, 

two of the note titles had not been incorporated into the 

electronic medical record menu nor were they linked to the 

CWAD posting. Therefore, we found that only two of five 

records reviewed for advance care planning documentation 

used the required progress note titles and were linked to the 

CWAD postings. 

Discharge Instructions. VHA requires that upon discharge 

from the facility, providers include information regarding 

medications, diet, activity level, and follow-up appointments 

in instructions to patients.11 In addition, The JC requires that 

clinicians provide patients with written discharge instructions. 

We reviewed the medical records of 10 discharged patients 

and found that diet instructions did not match diet orders at 

time of discharge in three of the records. For example, one 

patient was on a dysphagia12 diet with thickened liquids at 

the time of discharge; however, his discharge instructions 

stated that there were no restrictions on his diet. 

Recommendations	 9. We recommended that processes be strengthened to 

ensure that advance directive notification for inpatients is 

provided and documented. 

10. We recommended that the required progress note titles 

be used to document patient advance care planning and that 

the notes be linked to the CWAD posting in the electronic 

medical record. 

8 VHA Handbook 1004.02, Advance Care Planning and Management of Advance Directives, July 2, 2009.
 9 CWAD postings allow electronic medical record users to quickly access a status report of important items.

10 VHA Handbook 1004.02.
 11 VHA Handbook 1907.01.
 12 Dysphagia is a medical term for swallowing difficulty.
 

VA OIG Office of Healthcare Inspections 6 
CAP Review of the Wilmington VA Medical Center, Wilmington, DE 

11. We recommended that processes be strengthened to 

ensure that discharge instructions include appropriate diet 

orders. 

Review Activities Without Recommendations
 

Medication	 The purpose of this review was to determine whether the 

Management facility employed safe practices in the preparation, transport, 

and administration of hazardous medications, specifically 

chemotherapy, in accordance with applicable requirements. 

We observed the compounding and transportation of 

chemotherapy medications and the administration of those 

medications in the oncology clinic, and we interviewed 

employees. We determined that the facility safely prepared, 

transported, and administered the medications. We made no 

recommendations. 

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 C&P files and profiles and meeting minutes 

during which discussions about the physicians took place. 

We determined that the facility had implemented a consistent 

C&P process that met current requirements. We made no 

recommendations. 

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

recommendations and provided acceptable improvement plans. (See Appendixes D 

and E, pages 13–18, for the full text of the Directors’ comments.) We will follow up on 

the planned actions until they are completed. 

VA OIG Office of Healthcare Inspections 7 
CAP Review of the Wilmington VA Medical Center, Wilmington, DE 

Appendix A 

Facility Profile13 

Type of Organization Tertiary care medical center (intermediate) 

Complexity Level 2 

VISN 4 

CBOCs Dover, DE 

Georgetown, DE 

Cape May, NJ 

Ventnor, NJ 

Vineland, NJ 

Veteran Population in Catchment Area 115,290 

Type and Number of Total Operating Beds: 

 Hospital, including Psychosocial 

Residential Rehabilitation Treatment 

Program 

60 

 CLC/Nursing Home Care Unit 60 

 Other – 

Medical School Affiliation(s) Thomas Jefferson University 

University of Medicine and Dentistry of 

New Jersey 

Temple University 

 Number of Residents 66 

Resources (in millions): 

 Total Medical Care Budget 

Current FY (through 

October 2010) 

$167.2 

Prior FY (2010) 

$175.8 

 Medical Care Expenditures $36.3 $173.9 

Total Medical Care Full-Time Employee 

Equivalents 

Workload: 

 Number of Station Level Unique 

Patients 

 Inpatient Days of Care: 

o Acute Care 

891.6 

10,182 

1,649 

886.6 

25,870 

9,932 

o CLC/Nursing Home Care Unit 3,094 19,281 

Hospital Discharges 286 1,517 

Total Average Daily Census (including all bed 

types) (in percent) 

25.8 25.9 

Cumulative Occupancy Rate (in percent) 42.9 66.7 

Outpatient Visits 19,538 218,218 

13 All data provided by facility management. 

VA OIG Office of Healthcare Inspections 8 
CAP Review of the Wilmington VA Medical Center, Wilmington, DE 

Appendix B 

Follow-Up on Previous Recommendations 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

QM 

1. Consistently include QM/PI data in 

provider profiles for consideration at 

reprivileging. 

Ongoing professional practice evaluation 

plans were developed that include QM/PI 

data and are considered at reprivileging. 

Y N 

2. Ensure completion of required RCAs. Required RCAs were completed and were 

verified in the annual Risk Management 

Report in the November 2010 MEC 

minutes. 

Y N 

3. Ensure that moderate sedation and 

the use of reversal agents are monitored 

and reported to the appropriate 

committee. 

Surgical Care Review Committee minutes 

verify that reversal agents are monitored 

and reported to the appropriate committee. 

For FY 2010, no reversal agents were 

utilized. 

Y N 

4. Ensure that providers are privileged to 

perform procedures that are within the 

capability of the setting for which the 

privileges were requested and that all 

privilege actions are documented in the 

appropriate ECMS minutes. 

C&P folders now include setting-specific 

privileges, and actions are documented in 

the appropriate ECMS minutes. 

Y N 

EOC 

5. Ensure that all designated EOC team 

members participate in all EOC rounds 

and that all CBOCs are inspected 

semi-annually. 

EOC rounds and attendance 

documentation now reflect participation of 

designated team members in EOC rounds. 

Also, the EOC team inspects CBOCs 

semi-annually. 

Y N 

VA OIG Office of Healthcare Inspections 9 
CAP Review of the Wilmington VA Medical Center, Wilmington, DE 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

6. Ensure the reassessment of the 

number of individuals needed to 

participate in annual respirator fit testing 

to support current infectious disease 

programs. 

Following the 2008 CAP, meetings were 

held to reassess and define the staff to be 

fit tested. The number was increased 

during 2009–2010 in response to H1N1 

pandemic concerns, and those staff remain 

on a designated list. 

Y N 

COC 

7. Ensure that inter- and intra-facility 

medical record transfer documentation is 

complete. 

Inter- and intra-facility medical record 

transfer documentation is now being 

completed. 

Y N 

VA OIG Office of Healthcare Inspections 10 
CAP Review of the Wilmington VA Medical Center, Wilmington, DE 

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 63.2 66.8 66.9 76.0 66.0 50.2 55.8 56.5 

VISN 62.7 65.5 65.3 63.0 59.5 61.4 60.1 61.8 

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 Wilmington VA Medical Center, Wilmington, State DE 

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

conditions14 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 13.8 9.34 13.33 * 22.05 16.99 

VHA 13.31 9.73 15.08 20.57 21.71 15.85 

* Not enough cases 

14 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. 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. 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 Wilmington VA Medical Center, Wilmington, DE 

Appendix D 

VISN Director Comments 

Department of 

Veterans Affairs	 Memorandum 

Date: April 15, 2011
 

From: Director, VISN 4 (10N4)
 

Subject: CAP Review of the Wilmington VA Medical Center,
 

Wilmington, DE 

To:	 Director, Baltimore Office of Healthcare Inspections (54BA) 

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

1.	 I have reviewed the responses provided by the Wilmington VA Medical 

Center in Wilmington, DE and I am submitting it to your office as 

requested. 

2.	 If you have any questions or require additional information, please 

contact Barbara Forsha, VISN 4 Quality Management Officer at 

412-822-3290. 

(original signed by:) 

MICHAEL E. MORELAND, FACHE 

VA OIG Office of Healthcare Inspections 13 
CAP Review of the Wilmington VA Medical Center, Wilmington, DE 

Appendix E 

Facility Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: April 8, 2011
 

From: Director, Wilmington VA Medical Center (460/00)
 

Subject: CAP Review of the Wilmington VA Medical Center,
 

Wilmington, DE 

To: Director, VISN 4 (10N4) 

1. I have reviewed the draft report of the Inspector General’s Combined 

Assessment program (CAP) of the Wilmington VA Medical Center. We 

concur with the findings and recommendations. 

2. I appreciate the opportunity for this review as a continuing process to 

improve care to our Veterans. 

(original signed by:) 

CHARLES M DORMAN, FACHE 

Director 

VA OIG Office of Healthcare Inspections 14 
CAP Review of the Wilmington VA Medical Center, Wilmington, DE 

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 annual N95 respirator fit testing be 

completed and documented. 

Concur 

Target date for completion: June 1, 2011 

The Safety Manager is responsible to ensure fit testing of designated front line medical 

staff (ED, ICU, inpatient wards, and CLC). Fit testing occurs during daily operations and 

off shifts to accommodate staff. Tracking and documentation of fit testing is 

accomplished using an internal spreadsheet. Results are reported monthly by the 

Safety Manager to the Safety Committee. Our current compliance rate is 89%. 

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

medication security is maintained. 

Concur 

Target date for completion: July 1, 2011 

Pharmacy is inspecting all inpatient areas weekly for medication security. Nursing is 

developing a medication security inspection form to include all inpatient areas, on a 

rotating day and shift schedule. Results of inspections will be reported to Pharmacy 

and Therapeutic Committee for tracking and analysis of opportunities for improvement. 

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

QM-related committees develop specific action plans when problems are identified and 

track action items to completion. 

Concur 

Target date for completion: July 1, 2011 

The Performance Improvement Board will reeducate all boards, councils, and 

committees chairpersons and recording secretaries on the Medical Center 

Memorandum 460-00.20, WILMINGTON VA MEDICAL CENTER MEETING 

PRINCIPLES AND STRUCTURE that includes a standardized template that has a 

mandatory action item completion section. The Performance Improvement Board will 

assess and monitor that QM related committee minutes include discussion and 

documentation of opportunities for improvement and track items to completion. 

VA OIG Office of Healthcare Inspections 15 
CAP Review of the Wilmington VA Medical Center, Wilmington, DE 

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

analysis of data related to resuscitation episodes includes all required elements. 

Concur 

Target date for completion: July 1, 2011 

The Medical Center Memorandum 460-111.11 EMERGENCY MEDICAL CARE 

RESPONSE is under revision. The organization has added technique, equipment and 

delay in CPR, to the CPR tracking spreadsheet used to report CPR episodes. Results 

of all CPR episodes are reported to the Healthcare Delivery Council, which meets 

quarterly for analysis and opportunities for improvement. 

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

all required medical record review components are included and that results are 

reported quarterly. 

Concur 

Target date for completion: July 1, 2011 

The Medical Center Memorandum 460-136.53 HEALTH INFORMATION 

MANAGEMENT DOCUMENTATION POLICY AND PROCEDURES dated 

February 26, 2011 is complete and includes all required medical record review 

components in accordance with VHA Handbook 1907.01. The Medical Record 

Committee scorecard is being adjusted to include all required monitoring components 

with quarterly reports Medical Executive Board 

Recommendation 6. We recommended that the facility implement a plan to address 

the delivery of care to patients held in temporary bed locations. 

Concur 

Target date for completion: April 30, 2011 

A new Medical Center Memorandum 460-11.57 TEMPORARY BED LOCATION 

POLICY dated April 8, 2011, is complete. This new Medical Center Memorandum has 

been distributed to all facility service chiefs; education will occur at the service level. 

The Memorandum includes details on a monitoring process. Case Management, 

Utilization Management, and Risk Management will collaboratively review cases when 

the Full Capacity Plan is implemented and report results to the Performance 

Improvement Board. Review will evaluate patient flow throughout the organization and 

include at a minimum all required elements of monitoring in accordance with the VHA 

Directive. 

VA OIG Office of Healthcare Inspections 16 
CAP Review of the Wilmington VA Medical Center, Wilmington, DE 

Recommendation 7. 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: July 1.2011 

Our Education Resource Center has developed a new nursing template to be used for 

MDRO education of patients and family. Nursing staff are currently being in serviced on 

the new patient education templates. Approximately 50% of the inpatient nursing staff 

has documented training complete. Training included use of an MDRO template, 

infection prevention handouts, steps on how to complete medical record documentation, 

and a survey to assess understanding and use of the education materials. Initially our 

Quality Management department is monitoring the process, results are being reported 

to nursing leadership. Plan is for the monitoring process to be taken over by the Nurse 

Practice Council. 

Recommendation 8. We recommended that normal test results be consistently 

communicated to patients within the specified timeframe. 

Concur 

Target date for completion: July 1, 2011 

Facility is converting the Standard Operating Procedure on Normal Test Results, to a 

Medical Center Memorandum to strengthen accountability and enhance communication 

of the required reporting process to meet VHA Directive 2009-019. The new 

Memorandum will enhance performance monitoring. Results will be tracked by the 

Medical Record Council. Additionally, instances of non compliance will be reported to 

Service Chiefs. The Memorandum is being routed through the facility Memorandum 

process for review and concurrence. 

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

advance directive notification for inpatients is provided and documented. 

Concur 

Target date for completion: July 1, 2011 

Facility is revising the Medical Center Memorandum 460-11.18 ADVANCED 

HEALTHCARE PLANNING to include specific designation of who will perform, and 

document the Advanced Directive notification at the primary care visit and the initial 

inpatient assessment. 

VA OIG Office of Healthcare Inspections 17 
CAP Review of the Wilmington VA Medical Center, Wilmington, DE 

Recommendation 10. We recommended that the required progress note titles be used 

to document patient advance care planning and that the notes be linked to the CWAD 

posting in the electronic medical record. 

Concur 

Target date for completion: July 1, 2011 

This recommendation was implemented during the OIG visit. The Advanced Directive 

note was compliant. Rescinded Advanced Directive note was also linked to the CWAD 

posting area. The Advanced Directive Discussion note title was created, and linked to 

CWAD. Communication of changes will occur during our normal Center memo process, 

which includes review and concurrence by affected services. 

Recommendation 11. We recommended that processes be strengthened to ensure 

that discharge instructions include appropriate diet orders. 

Concur 

Target date for completion: July 1, 2011 

Our Facility is exploring a way to automatically import diet orders into the discharge 

instruction form, where they could be confirmed or reconciled with any changes that 

occurred during the admission. 

VA OIG Office of Healthcare Inspections 18 
CAP Review of the Wilmington VA Medical Center, Wilmington, DE 

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 Melanie Cool, LD, Project Leader 

Kimberly Pugh, RN, Team Leader 

Gail Bozzelli, RN 

Jennifer Christensen, DPM 

Myra Conway, RN 

Frank Miller, PhD 

Judith Thomas, RN 

Sonia Whig, LD 

Rutledge Davis III, BS, Program Support Assistant 

John Dattoria, Special Agent, Office of Investigations 

VA OIG Office of Healthcare Inspections 19 
CAP Review of the Wilmington VA Medical Center, Wilmington, DE 

Appendix G 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VISN 4 (10N4) 

Director, Wilmington VA Medical Center (460/00) 

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: Thomas R. Carper, Christopher A. Coons 

U.S. House of Representatives: John Carney 

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

VA OIG Office of Healthcare Inspections 20