Department of Veterans Affairs 

Office of Inspector General 

Office of Healthcare Inspections
	

Report No. 10-03092-129

Combined Assessment Program
	

Review of the
	

Richard L. Roudebush
	

VA Medical Center
	

Indianapolis, Indiana
	

March 23, 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 Richard L. Roudebush VA Medical Center, Indianapolis, IN

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

CPR cardiopulmonary resuscitation

CPRS Computerized Patient Record System

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

and Directives

ECMS Executive Committee of the Medical Staff

EOC environment of care

facility Richard L. Roudebush VA Medical Center

FPPE Focused Professional Practice Evaluation

FTE full-time employee equivalents

FY fiscal year

IC infection control

JC Joint Commission

LMS Learning Management System

MDRO multidrug-resistant organisms

MH mental health

OIG Office of Inspector General

OPPE Ongoing Professional Practice Evaluation

OSHA Occupational Safety and Health Administration

PPE personal protective equipment

PRRTP Psychosocial Residential Rehabilitation Treatment

Program

PSB Professional Standards Board

QM quality management

RCA root cause analysis

SHEP Survey of Healthcare Experiences of Patients

SOPs standard operating procedures

VHA Veterans Health Administration

VISN Veterans Integrated Service Network

VA OIG Office of Healthcare Inspections
CAP Review of the Richard L. Roudebush VA Medical Center, Indianapolis, IN

Table of Contents
	

Page
	

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

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

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

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

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

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

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

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

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

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

COC .................................................................................................................. 7
 

Management of MDRO...................................................................................... 9
 

Follow-Up on Background Investigations .......................................................... 9
 

Review Activity Without Recommendations............................................................ 10
 

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

Comments................................................................................................................... 10
 

Appendixes 

A. Facility Profile .................................................................................................... 11
 

B. Follow-Up on Previous Recommendations........................................................ 12
 

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 ......................................................... 25
 

G. Report Distribution ............................................................................................ 26
 

VA OIG Office of Healthcare Inspections
 

Executive Summary: Combined Assessment Program 

Review of the Richard L. Roudebush VA Medical Center, 

Indianapolis, IN 

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

December 13, 2010.

Review Results: The review covered

seven activities and one follow-up

review area. We made no

recommendations in the following

activity:

 Medication Management

Recommendations: We made

recommendations in the following six

activities and follow-up review area:

Quality Management: Ensure moderate

sedation documentation includes all

required components, and monitor

compliance. Provide oversight of

medical record review. 

Environment of Care: Ensure

designated employees complete

required training, and document it.

Routinely clean ice machines. Ensure

fire extinguishers are accessible to

mental health staff. Inspect radiation

shields annually. Secure computer

screens. Ensure oxygen tanks are

properly labeled and stored.

Physician Credentialing and Privileging: 

Make and document two requests to

verify physicians’ privileges. Ensure the

Executive Committee of the Medical

Staff reviews and documents privileging

recommendations prior to making final

recommendations. Initiate focused

evaluations as required. Create,

approve, and implement service-specific

competency criteria.

Management of Test Results: Document

the time critical results were

communicated. Document notification

and treatment actions for critical results.

Monitor the test result communication

process. Communicate normal results

within the defined timeframe.

Coordination of Care: Provide and

document advance directive notification

and screening. Scan advance directives

into medical records. Ensure advance

directives on the VA form are

appropriately witnessed.

Management of Multidrug-Resistant 

Organisms: Provide infection prevention

strategies education to affected patients

and their families. Ensure employees

receive annual education, and

document it.

Follow-Up on Background 

Investigations: Timely complete

background investigations.

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.

(original signed by:) 

JOHN D. DAIGH, JR., M.D.
 

Assistant Inspector General for
 

Healthcare Inspections
 

VA OIG Office of Healthcare Inspections i 
CAP Review of the Richard L. Roudebush VA Medical Center, Indianapolis, IN

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 Background Investigations

	 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 December 17, 2010, and was done in

accordance with OIG SOPs for CAP reviews. We also

followed up on selected recommendations from our prior

CAP review of the facility (Combined Assessment 

Program Review of the Richard L. Roudebush VA Medical 

VA OIG Office of Healthcare Inspections 1
CAP Review of the Richard L. Roudebush VA Medical Center, Indianapolis, IN

Center, Indianapolis, Indiana, Report No. 08-00401-133,

May 29, 2008). (See Appendix B for further details.) The

facility had repeat findings in the areas of physician C&P

(formerly part of the QM review) and follow-up on

background investigations.

During this review, we also presented crime awareness

briefings for 76 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.

Moderate Sedation. VHA requires that staff assess and

monitor patients undergoing moderate sedation.1 We

reviewed the medical records of patients who underwent

moderate sedation and found that only 4 of the 10 records

included documentation of all required elements, such as

airway assessment, assessment of risk, and re-evaluation

immediately prior to the procedure.

Medical Records Quality Review. VHA requires that facilities

have a medical record review committee or its equivalent.2

The committee must provide oversight and coordination of

the review process, determine the frequency of reviews, and

analyze review reports to identify problems or opportunities

for improvement. The facility did not have a medical record

review committee and assigned the equivalent function to the

1 VHA Directive 2006-023, Moderate Sedation by Non-Anesthesia Providers, May 1, 2006. 2 VHA Handbook 1907.01, Health Information Management and Health Records, August 25, 2006. 

VA OIG Office of Healthcare Inspections 2
CAP Review of the Richard L. Roudebush VA Medical Center, Indianapolis, IN

Recommendations 

EOC 

ECMS. We reviewed local policy and ECMS minutes for the

period November 2009 to October 2010. The facility’s

current ECMS policy does not reference the medical record

review committee requirements. ECMS minutes did not

document committee oversight or coordination of the medical

record quality review process, establish frequency of

reviews, or analyze health record quality review reports.

1. We recommended that moderate sedation

documentation include all required components and that

supervisors monitor compliance.

2. We recommended that medical record quality review

oversight be provided.

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 rehabilitation, MH, medicine, surgery, and

surgical intensive care units; the primary care and women’s

clinics; the emergency room; and radiology. Additionally, we

walked through the facility’s offsite annexed primary care

clinic and the domiciliary. The facility maintained a generally

clean and safe environment.

During our inspection of the MH inpatient unit, we found that

the exit door alarm to the stairs was nonfunctional. However,

the door alarm was operational upon our return to the unit

2 days later; therefore, we made no recommendation for this

finding.

During our inspection of radiology, we found sterile gauze

pads that had been opened and taped to a machine at the

beginning of the day for use on patients throughout the day.

This practice did not maintain product sterility prior to use.

Leadership had the gauze pads and tape removed from the

machine; therefore, we made no recommendation for this

finding. However, we identified the following conditions that

needed improvement.

IC. OSHA requires that all employees receive initial and

annual training on the OSHA Bloodborne Pathogens Rule.

We reviewed employee training records and found that

16 of the 18 records had this training documented.

If facilities use N95 respirators, OSHA requires that

designated employees be fit tested annually. We reviewed

VA OIG Office of Healthcare Inspections 3
Recommendations
	

CAP Review of the Richard L. Roudebush VA Medical Center, Indianapolis, IN

employee training records and determined that

24 (57 percent) of the 42 records had the required annual fit

testing documented.

On two separate inpatient units, we found dirt or rust buildup

on patient ice machines.

Fire Safety. OSHA requires that staff have readily

accessible fire extinguishers. The inpatient MH unit had one

fire extinguisher located behind two locked doors. Not all

staff had keys to both of these locked doors.

Radiology. OSHA requires that the facility implement

procedures for periodically inspecting the integrity of

radiation shields and aprons. The facility requires staff to

visually inspect radiation shields and aprons annually. We

determined that 192 (77 percent) of the 250 shields and

aprons had documented visual inspection dates within the

last year.

Facility management requires annual LMS radiation safety

education training for designated radiology staff. We

reviewed LMS records for five radiology technicians and

determined that only two of the records had this training

documented.

Patient Privacy. The Health Insurance Portability and

Accountability Act requires confidential patient information to

be secured. On multiple inpatient units, we found computers

displaying patient information. These computers were

located in hallways and were easily viewable by anyone

passing by.

Oxygen Tank Storage. During our follow-up on previous

CAP recommendations, we identified new issues with

oxygen tanks. The JC requires that facilities label oxygen

tanks as full or empty and that clean and dirty supplies are

stored separately. We found oxygen tanks that were not

identified as full or empty and oxygen tanks that were stored

with clean supplies.

3. We recommended that required annual bloodborne

pathogens training, radiation safety training, and

N95 respirator fit testing be completed by designated

employees and documented.

VA OIG Office of Healthcare Inspections 4
CAP Review of the Richard L. Roudebush VA Medical Center, Indianapolis, IN

4. We recommended that patient ice machines be routinely

cleaned.

5. We recommended that inpatient MH staff have readily

accessible fire extinguishers.

6. We recommended that radiation shields be visually

inspected annually.

7. We recommended that computer screens displaying

patient information on inpatient units be secured from

unauthorized personnel.

8. We recommended that oxygen tanks be clearly labeled

as full or empty and stored appropriately.

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 14 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.

Privileges. VHA requires facilities to send a minimum of two

requests to verify that a physician’s currently held or most

recently held clinical privileges are in good standing.3 None

of the credentialing files reviewed contained the physician’s

currently or most recently held clinical privileges or

documentation to support that staff made at least two

attempts at verification.

Privileging Recommendations. VHA requires PSB privileging

recommendations to be submitted to the ECMS for

evaluation and final recommendation to the facility Director.

ECMS meeting minutes did not document review or approval

of any PSB privileging recommendations during the review

period.

FPPE. VHA requires that an FPPE be initiated for all

physicians who have been newly hired or have added new

privileges. We reviewed newly hired physicians’ profiles and

determined that two of three profiles had an FPPE initiated.

3 VHA Handbook 1100.19, Credentialing and Privileging, November 14, 2008. All references to VHA 

requirements in this section pertain to this handbook. 

VA OIG Office of Healthcare Inspections 5
CAP Review of the Richard L. Roudebush VA Medical Center, Indianapolis, IN

OPPE. VHA requires that data consistent with

service-specific competency criteria be defined; collected;

maintained in each physician’s profile; and reviewed on an

ongoing, periodic basis. We reviewed physician profiles and

determined that six of the eight applicable profiles contained

sufficient data to support reprivileging. This is a repeat

finding from the previous CAP review. Further, not all

service-specific competency criteria used for reprivileging

were approved by the ECMS.

Recommendations		 9. We recommended that at least two requests to verify

physicians’ currently held or most recently held clinical

privileges be made and documented.

10. We recommended that the ECMS review and document

PSB privileging recommendations prior to making final

recommendations to the facility’s Director.

11. We recommended that FPPEs be initiated for all

physicians who have been newly hired or have added new

privileges.

12. We recommended that service-specific competency

criteria be created, approved, and implemented.

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.4

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 clinicians document in the medical

record the time and means of critical test result

communication and the name of the ordering provider

contacted.5 We reviewed the medical records of patients

who had critical results and found that diagnostic clinicians

documented the time the ordering provider was notified in

26 (87 percent) of the 30 records.

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

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

requirements in this section pertain to this directive.
 

VA OIG Office of Healthcare Inspections 6
CAP Review of the Richard L. Roudebush VA Medical Center, Indianapolis, IN

Recommendations 

COC 

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 patients who

had critical results and found documented evidence of

patient notification and follow-up actions in 25 (83 percent) of

the 30 records.

Monitoring Results Communication. VHA requires facilities

to monitor the effectiveness of communication of results to

providers and patients. We did not find evidence that

radiology staff monitored the effectiveness of communication

of results to ordering providers.

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 patients who had normal results and found that

12 of the 20 records contained documented evidence that

the facility had communicated the results to the patients.

13. We recommended that diagnostic clinicians consistently

document the time critical results were communicated to

ordering providers.

14. We recommended that ordering providers document

patient notification and treatment actions in response to

critical results.

15. We recommended that the process of communicating

test results to providers and patients be periodically

monitored for effectiveness.

16. We recommended that normal test results be

consistently communicated to patients within the specified

timeframe.

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 24 patients’ medical records for evidence of

advance care planning, advance directives, and discharge

instructions. We identified the following areas that needed

improvement.

VA OIG Office of Healthcare Inspections 7
CAP Review of the Richard L. Roudebush VA Medical Center, Indianapolis, IN

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.6 We found

evidence of written notification in 18 of the 24 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 19 of the

24 medical records.

Management of Advance Directive Documents. VHA

requires that advance directives be filed in patient medical

records. VHA also requires that advance directives

documented on the VA form be witnessed by two individuals

and offered to patients once completed. Nine of the

24 medical records indicated the presence of advance

directives, all of which had been created using the VA form.

Electronic copies of advance directives were present in eight

of the nine records. None of the nine records contained

documentation that patients received a copy of the

completed advance directive. Witness signatures were

present on seven of the eight viewable advance directives.

VHA 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 6 of 21 applicable medical

records.

Recommendations		 17. We recommended that procedures be implemented to

ensure that staff provide and document advance directive

notification and screening at each inpatient admission.

18. We recommended that procedures be implemented 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.

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

references to VHA requirements in this section pertain to this handbook. 

VA OIG Office of Healthcare Inspections 8
CAP Review of the Richard L. Roudebush VA Medical Center, Indianapolis, IN

Management of 

MDRO 

Recommendations 

Follow-Up on 

Background 

Investigations 

19. We recommended that advance directives developed

using the VA form be appropriately witnessed and that a

copy of the completed document be provided to the patient.

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 two inpatient medical units and interviewed

seven employees and 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 colonized7 with MDRO and their families; receive

education on infection prevention strategies, such as hand

washing and the proper use of PPE. We reviewed medical

records and found that only 15 of the 19 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 employee training

records to determine whether MDRO education had been

provided in accordance with the risk assessment. We found

that only 13 of the 16 records reviewed had documentation

of annual MDRO education.

20. We recommended that infection prevention strategies

education be provided to patients infected or colonized with

MDRO and their families and be documented.

21. We recommended that employees receive annual

MDRO education and that the training be consistently

documented.

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

review, we reassessed facility compliance with timely

completion of background investigations. VA requires

completion of the appropriate level of background screening

for appointees prior to access to VA systems.8 We validated

the facility’s statement that only 90 percent of current

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

8 VA Directive 0710, Personnel Security and Suitability Program, June 4, 2010. 

VA OIG Office of Healthcare Inspections 9
CAP Review of the Richard L. Roudebush VA Medical Center, Indianapolis, IN

appointees had background screenings completed within the

required timeframes.

Recommendation		 22. We recommended that processes be implemented to

ensure timely completion of background investigations.

Review Activity Without Recommendations
	

Medication 

Management 

The purpose of this review was to determine whether the

facility employed safe practices in the preparation, transport,

and administration of hazardous medications, specifically

chemotherapy, in accordance with applicable requirements.

We observed the compounding and transportation of

chemotherapy medications and the administration of those

medications in the oncology clinic, and we interviewed

employees. We determined that the facility safely prepared,

transported, and administered the medications. We made no

recommendations.

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

recommendations and provided acceptable improvement plans. (See Appendixes D

and E, pages 17–24, 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 10
CAP Review of the Richard L. Roudebush VA Medical Center, Indianapolis, IN

Appendix A 

Facility Profile9 

Type of Organization Tertiary care

Complexity Level 1A

VISN 11

CBOCs Bloomington, IN

Terre Haute, IN

Veteran Population in Catchment Area 187,000

Type and Number of Total Operating Beds: 

 Hospital, including PRRTP 209

 CLC/Nursing Home Care Unit 0

 Other 0

Medical School Affiliation(s) Indiana University School of Medicine

 Number of Residents 122

Resources (in millions): 

 Total Medical Care Budget 

FY 2010 

$363.3

Prior FY 

$335.3

 Medical Care Expenditures $400 $371.4

Total Medical Care FTE 

Workload: 

 Number of Station Level Unique 

Patients 

 Inpatient Days of Care: 

o Acute Care 

2,230.8

55,840

47,790

2,164.9

53,954

44,242

o CLC/Nursing Home Care Unit 0 0

Hospital Discharges 8,589 8,402

Total Average Daily Census (including all bed 

types) 

164 168.2

Cumulative Occupancy Rate 78.5% 80.5%

Outpatient Visits 541,045 494,318

9 All data provided by facility management. 

VA OIG Office of Healthcare Inspections 11
CAP Review of the Richard L. Roudebush VA Medical Center, Indianapolis, IN

Appendix B 

Follow-Up on Previous Recommendations 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

QM 

1. Ensure that the C&P process is

completed in compliance with VHA policy.

After the previous CAP, a standard

format was developed for reporting

provider performance data quarterly to

the Credentialing Office. Compliance

is at 94 percent, and work continues for

submission of quality and meaningful

performance data.

N Y (see page 6)

2. Ensure that all clinically active staff

maintain current CPR training.

Management tracks compliance, and

Education Service offers training

locally. Compliance is at 98 percent.

Y N

3. Meet VHA requirements for peer reviews. Management revised practices and

increased Peer Review Committee

meetings to twice per month. Timely

completion of peer reviews is at

100 percent.

Y N

4. Require that patient safety complaint data

is compared to data from the SHEP survey

and that findings are reported to an

oversight committee for corrective action.

Data is trended and reviewed through

the Indy Excellence Service Team and

several other forums.

Y N

5. Meet VHA requirements for RCAs. Management continues to use a

system to track the status of RCAs and

corrective actions. Since

September 2009, 100 percent of all

RCAs and actions have been

completed on time.

Y N

VA OIG Office of Healthcare Inspections 12
CAP Review of the Richard L. Roudebush VA Medical Center, Indianapolis, IN

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

6. Meet VHA requirements for the utilization

management program.

Assignment of a physician advisor is

complete, and the Utilization

Management/Patient Flow Committee

monitors action items.

Y N

7. Ensure that analyzed data from the Code

Committee are presented to an oversight

committee for corrective actions.

Code Committee minutes are

presented to the ECMS for oversight of

problem resolution.

Y N

8. Develop a policy for importing and/or

copying text into CPRS.

A policy is in place. Y N

9. Ensure that all restraint and seclusion

data are presented to an oversight

committee and that data are monitored and

that action items are implemented.

Restraint and seclusion data are

presented to and monitored through

the ECMS.

Y N

EOC 

10. Require safety and IC vulnerabilities to

be corrected.

Central refrigeration monitors are in

use, access to medication rooms has

been restricted, and oxygen tanks are

secured and stored properly.

Environmental rounds to monitor the

condition of furnishings are ongoing.

Y N

11. Require sensitive information to be

protected from unauthorized access.

Sensitive patient information has been

removed from the inside and outside of

patients’ rooms.

Y N

CPRS Business Rules 

12. Require CPRS business rules to comply

with VHA policy and Office of Information

guidance.

Policy is in place, and the

October 4, 2004, CPRS informational

patch was installed.

Y N

VA OIG Office of Healthcare Inspections 13
CAP Review of the Richard L. Roudebush VA Medical Center, Indianapolis, IN

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

Follow-Up of Background Investigations 

13. Comply with policies governing VHA

employment screening requirements, and

correct the identified discrepancies.

Compliance is at approximately

90 percent with current practices.

N Y (see pages 9–10)

VA OIG Office of Healthcare Inspections 14
CAP Review of the Richard L. Roudebush VA Medical Center, Indianapolis, IN

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

quarters 1–3 of FY 2010.

Table 1 

FY 2010

(inpatient target = 64, outpatient target = 56)

Inpatient

Score

Quarter 1

Inpatient

Score

Quarter 2

Inpatient

Score

Quarter 3

Outpatient

Score

Quarter 1

Outpatient

Score

Quarter 2

Outpatient

Score

Quarter 3

Facility 70.9 68.2 67.1 53.6 56.5 61.8

VISN 67.4 66.1 65.6 53.4 54.5 56.3

VHA 63.3 63.9 64.5 54.7 55.2 54.8

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 15
CAP Review of the Richard L. Roudebush VA Medical Center, Indianapolis, IN

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

conditions10 received hospital care. The mortality (or death) rates focus on whether

patients died within 30 days of their hospitalization. The rates of readmission focus on

whether patients were hospitalized again within 30 days. Mortality rates and rates of

readmission show whether a hospital is doing its best to prevent complications, teach

patients at discharge, and ensure patients make a smooth transition to their home or

another setting. The hospital mortality rates and rates of readmission are based on

people who are 65 and older. These comparisons are “adjusted” to take into account

their age and how sick patients were before they were admitted to the VA facility.

Table 2 below shows the facility’s Hospital Outcome of Care Measures for

FYs 2006–2009.

Table 2 

Mortality Readmission

Heart Attack CHF Pneumonia Heart Attack CHF Pneumonia

Facility 14.44 9.42 13.84 22.17 23.21 16.6

VHA 13.31 9.73 15.08 20.57 21.71 15.85

10 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 16
CAP Review of the Richard L. Roudebush VA Medical Center, Indianapolis, IN

Appendix D 

VISN Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: February 18, 2011

From: Director, VISN 11 (10N11)

Subject: CAP Review of the Richard L. Roudebush VA Medical 

Center, Indianapolis, IN 

To: Director, Dallas Healthcare Inspections Division (54DA)

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

I concur with the recommendations and action plans in the attached

memorandum from the Richard L. Roudebush VA Medical Center.

(original signed by:)

Michael Finegan, FACHE

Veterans in Partnership Director, VISN 11

VA OIG Office of Healthcare Inspections 17
CAP Review of the Richard L. Roudebush VA Medical Center, Indianapolis, IN

Appendix E 

Facility Director Comments 

Department of 

Veterans Affairs Memorandum 

Date:		 February 18, 2011

From:		 Director, Richard L. Roudebush VA Medical Center

Subject:		 CAP Review of the Richard L. Roudebush VA Medical 

Center, Indianapolis, IN 

To:		 Director, VISN 11 (10N11)

This memorandum serves as our concurrence with the recommendations

found in this CAP review. Corrective actions completed and planned have

been attached.

(original signed by:)

Thomas Mattice, FACHE

Richard L. Roudebush VA Medical Center Director

VA OIG Office of Healthcare Inspections 18
CAP Review of the Richard L. Roudebush VA Medical Center, Indianapolis, IN

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 moderate sedation documentation

include all required components and that supervisors monitor compliance.

Concur 

Target Completion Date: Action Completed.

Quality Management staff has met with areas providing moderate sedation. Elements

have been added to the existing CPRS template. For areas utilizing paper, physicians

have been reminded that they must fill out their portion which is scanned into the EMR

after the procedure. Monitoring will be completed to ensure compliance.

Recommendation 2. We recommended that medical record quality review oversight

be provided.

Concur 

Target Completion Date: April 30, 2011.

The facility is developing criteria to identify the pertinent medical record (MR) quality

review activities to be reported to the ECMS and will establish a mechanism including

appropriate staff for reporting MR activities and providing feedback on findings that

require improvement actions.

Recommendation 3. We recommended that required annual bloodborne pathogens

training, radiation safety training, and N95 respirator fit testing be completed by

designated employees and documented.

Concur 

Target Completion Date: June 30, 2011

Radiation safety was assigned via LMS and is 100% complete. Annual bloodborne

pathogens training is assigned to employees and monitored via annual performance

and competency reviews. Review will be conducted to ensure that staff are current on

training. Only staff who have been fit tested are permitted to enter isolation rooms.

Safety Office has expanded its Fit Testing service an additional day. In addition, the

Safety Office has presented material at Patient Care Manager meetings on Fit Testing

and PAPR training. Thirdly, the Safety Office developed, assigned, and is monitoring a

LMS module required for all Patient Care staff on isolation procedures and PPE

VA OIG Office of Healthcare Inspections 19
CAP Review of the Richard L. Roudebush VA Medical Center, Indianapolis, IN

(including respiratory protection). Policy will be evaluated to determine who is required

to have fit testing and a review conducted to ensure compliance. Ongoing monitoring

will occur through annual competency evaluations and annual performance reviews.

Recommendation 4. We recommended patient ice machines be routinely cleaned.

Concur 

Target Completion Date: Action Completed.

EMS staff members have been instructed to clean patient ice machines. Ongoing

monitoring will occur through Environment of Care rounds and through EMS

Supervisors inspections.

Recommendation 5. We recommended that inpatient MH staff have readily accessible

fire extinguishers.

Concur
	

Target Completion Date: Action Completed.
 

Fire extinguisher has been installed and inspected.
 

Recommendation 6. We recommended that radiation shields be visually inspected
 

annually.
 

Concur
	

Target Completion Date: Action Completed.
 

Facility has ensured that 100% of radiation shields have been inspected.
 

Recommendation 7. We recommended that computer screens displaying patient
 

information on inpatient units be secured from unauthorized personnel.
 

Concur 

Target Completion Date: April 30, 2011.

The Indianapolis Privacy Workgroup has developed an education campaign to educate

staff which includes targeted messages and meeting with supervisors. EOC rounds will

continue to identify PCs that require privacy screens. ISO/PO will increase visits to all

areas, to identify PCs that require privacy screens. With regard to Privacy Screens, the

following steps will be performed to protect unauthorized viewing of info on computer

monitors: Re-positioning the monitor; installing a privacy screen; Re-positioning monitor

with privacy screens, so no one can stand directly behind you; and a campaign to alert

staff to be aware of who is directly behind them.

VA OIG Office of Healthcare Inspections 20
CAP Review of the Richard L. Roudebush VA Medical Center, Indianapolis, IN

Recommendation 8. We recommended that oxygen tanks be clearly labeled as full or

empty and stored appropriately.

Concur 

Target Completion Date: March 30, 2011

Oxygen tanks will not be labeled with tags as oxygen level can be determined by

viewing gauge. Facility procedure is to store full and empty tanks in separate locations

(full tank = >1000 psi, empty tank = <1000psi). Signage will be placed to differentiate

correct location to store either full or empty tanks. Oxygen tanks will not be stored with

clean supplies. Safety and Chief PCS Clinical Support have reviewed areas and

implemented appropriate storage locations. A monitor has been developed to track

compliance and will be reported through Nursing PI Council.

Recommendation 9. We recommended that at least two requests to verify physicians’

currently held or most recently held clinical privileges be made and documented.

Concur 

Target Completion Date: June 30, 2011

Credentialing staff have begun to follow-up with an additional request when affiliation

verifications are received without the requested copy of currently held or most recent

clinical privileges. Non-receipt will be documented. Staff will review current files and

ensure documentation of at least two requests are present.

Recommendation 10. We recommended that the ECMS review and document PSB

privileging recommendations prior to making final recommendations to the facility’s

Director.

Concur 

Target Completion Date: Action Complete.

Credentialing staff have begun to forward requested privileges. The Executive

Committee of the Medical Staff’s voting members will review and make

recommendation to the Director on all privileging and medical staff appointment actions.

Recommendation 11. We recommended that FPPEs be initiated for all physicians

who have been newly hired or have added new privileges.

Concur 

Target Completion Date: Action Completed.

Processed has been changed and FPPE’s will be initiated for a newly appointed

physician or for new clinical privileges upon entry on duty date.

VA OIG Office of Healthcare Inspections 21
CAP Review of the Richard L. Roudebush VA Medical Center, Indianapolis, IN

Recommendation 12. We recommended that service-specific competency criteria be

created, approved, and implemented.

Concur 

Target Completion Date: June 30, 2011.

Service-specific competency criteria for the Ongoing Professional Performance

Evaluation process is currently being developed by each clinical service chief. Several

revised OPPE templates have been reviewed and recommended for use at the January

and February 2011 ECMS meetings. The rest will be completed by the target date.

Recommendation 13. We recommended that diagnostic clinicians consistently

document the time critical results were communicated to ordering providers.

Concur 

Target Completion Date: April 30, 2011.

Radiology Service is developing a process for communication of critical test results.

Draft Medical Center Memorandum will be forwarded to the Executive Committee of the

Medical Staff.

Recommendation 14. We recommended that ordering providers document patient

notification and treatment actions in response to critical results.

Concur 

Target Completion Date: May 30, 2011.

Ordering providers will be reminded of requirements to document patient notification

and treatment actions.
 

Recommendation 15. We recommended that the process of communicating test
 

results to providers and patients be periodically monitored for effectiveness.
 

Concur
	

Target Completion Date: June 30, 2011.
 

Medical Center Memorandum related to communication of test results will include
 

development of process for periodic monitoring.
 

Recommendation 16. We recommended that normal test results be consistently
 

communicated to patients within the specified timeframe.
 

Concur
	

Target Completion Date: June 30, 2011.
 

VA OIG Office of Healthcare Inspections 22
CAP Review of the Richard L. Roudebush VA Medical Center, Indianapolis, IN

Inpatient discharge instructions have been modified to ensure communication of all test

results has occurred prior to discharge. Medical Center Memorandum will be drafted

outlining processes and forwarded to ECMS. Weekly meetings with Ambulatory Care

will continue to roll out reminder and improve compliance. Expansion to Specialty

clinics will be implemented.

Recommendation 17. We recommended that procedures be implemented to ensure

that staff provide and document advance directive notification and screening at each

inpatient admission.

Concur 

Target Completion Date: April 30, 2011.

Chief Social Work Service will meet with screeners and re-establish expectation of

100% screening at the required times. Provide training to screeners to educate on

mandatory dissemination of VA Form 10-0137A. 

Recommendation 18. We recommended that procedures be implemented 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 Completion Date: Action Completed.

Link has been enabled and quarterly monitoring of link by Clinical Applications

Coordinator to verify it remains activated has been established.

Recommendation 19. We recommended that advance directives developed using the

VA form be appropriately witnessed and that a copy of the completed document be

provided to the patient.

Concur 

Target Completion Date: April 30, 2011.

The Chief of Social Work Service is overseeing process. Process will include

development of a new CPRS consult to be activated by screening clerks when patient

desires to complete an Advance Directive. The consult will be processed by Chief, SW

Service (with appropriate designees) and directed to appropriate Social Work staff (and

back-up designees). He will educate Social Work staff and designees regarding

expectations: a) for witnessing signing of advance directive by patient, b) for proper

recording in the electronic medical record (either through direct entry or scanning paper

forms) and c) for providing the original or printed copy of a signed iMedConsentTM

version of the advance directive to the patient. Additionally, Social Work staff and

designees will be educated on documentation requirements for advance directives,

VA OIG Office of Healthcare Inspections 23
CAP Review of the Richard L. Roudebush VA Medical Center, Indianapolis, IN

including documentation of the offer to provide the patient with signed advance

directive.

Recommendation 20. We recommended that infection prevention strategies education

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

documented.

Concur 

Target Completion Date: Completed.

Education documentation was added to the PICIS ICU charting system to include

infection prevention strategies.

Recommendation 21. We recommended that employees receive annual MDRO

education and that the training be consistently documented.

Concur 

Target Completion Date: June 30, 2011.

Staff are being identified for assignment of learning module in LMS. Once identified,

module will be assigned and staff will be instructed to complete. Monitoring will occur

through annual competency and performance review.

Recommendation 22. We recommended that processes be implemented to ensure

timely completion of background investigations.

Concur 

Target Completion Date: May 15, 2011.

During the time of the review the facility was at 94%; however, opportunity for

improvement was noted. Actions to improve timely completion of background related

especially to contract personnel include designation of sensitivity when submitting

Statement of Work to Contracting, providing instruction sheet on the process for

successful bidders, meeting with current contractors to review process, Contracting will

provide access to logs of initiated background investigations to cross check that no one

provides services without initiating a background investigation.

VA OIG Office of Healthcare Inspections 24
CAP Review of the Richard L. Roudebush VA Medical Center, Indianapolis, IN

Appendix F 

OIG Contact and Staff Acknowledgments 

Contact Cathleen King, RN, Associate Director

Dallas Office of Healthcare Inspections

Contributors Katharine Foster, RN

Gayle Karamanos, PA

Sandra Khan, RN

Daniel Kolb, PhD

Sarah Lutter, RN, JD

Karen Moore, RN

Larry Ross, MS

Maureen Washburn, ND

Julie Watrous, RN

Misti Kincaid, BS, Program Support Assistant

Gregg Hirstein, Office of Investigations

VA OIG Office of Healthcare Inspections 25
CAP Review of the Richard L. Roudebush VA Medical Center, Indianapolis, IN

Appendix G 

Report Distribution 

VA Distribution 

Office of the Secretary

Veterans Health Administration

Assistant Secretaries

General Counsel

Director, Veterans in Partnership (10N11)

Director, Richard L. Roudebush VA Medical Center (583/00)

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: Daniel Coats, Richard G. Lugar

U.S. House of Representatives: Larry Bucshon, Dan Burton, Andre Carson,

Mike Pence, Todd Rokita, Todd Young

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

VA OIG Office of Healthcare Inspections 26