Department of Veterans Affairs 

Office of Inspector General 

Office of Healthcare Inspections
 

Report No. 10-02984-54 

Combined Assessment Program
 

Review of the
 

Boise VA Medical Center
 

Boise, Idaho
 

January 10, 2011 

Washington, DC 20420
 
Why We Did This Review 

Combined Assessment Program (CAP) reviews are part of the Office of Inspector 

General's (OIG's) efforts to ensure that high quality health care is provided to our 

Nation's veterans. CAP reviews combine the knowledge and skills of the OIG's Offices 

of Healthcare Inspections and Investigations to provide collaborative assessments of 

VA medical facilities on a cyclical basis. The purposes of CAP reviews are to: 

 Evaluate how well VA facilities are accomplishing their missions of providing veterans 

convenient access to high quality medical services. 

 Provide crime awareness briefings to increase employee understanding of the 

potential for program fraud and the requirement to refer suspected criminal activity to 

the OIG. 

In addition to this typical coverage, CAP reviews may examine issues or allegations 

referred by VA employees, patients, Members of Congress, or others. 

To Report Suspected Wrongdoing in VA Programs and Operations 

Telephone: 1-800-488-8244 

E-Mail: vaoighotline@va.gov 

(Hotline Information: http://www.va.gov/oig/contacts/hotline.asp) 
CAP Review of the Boise VA Medical Center, Boise, ID 

Glossary 

C&P credentialing and privileging 

CAP Combined Assessment Program 

CBOC community based outpatient clinic 

CDC Centers for Disease Control and Prevention 

CHF congestive heart failure 

CLC community living center 

CNH community nursing home 

COC coordination of care 

ED emergency department 

EOC environment of care 

facility Boise VA Medical Center 

FTE full-time employee equivalents 

FY fiscal year 

GI gastrointestinal 

HCA health care agent 

HCHV Health Care for Homeless Veterans 

ICU intensive care unit 

JC Joint Commission 

LMS Learning Management System 

MDRO multidrug-resistant organisms 

MEC Medical Executive Committee 

MH mental health 

NIOSH National Institute for Occupational Safety and Health 

OIG Office of Inspector General 

OPPE Ongoing Professional Practice Evaluation 

OSHA Occupational Safety and Health Administration 

PAPR powered air-purifying respirator 

PM performance measures 

PPE personal protective equipment 

PRRTP Psychosocial Residential Rehabilitation Treatment 

Program 

QM quality management 

RN registered nurse 

SOPs standard operating procedures 

SW social worker 

TB tuberculosis 

UM utilization management 

VHA Veterans Health Administration 

VISN Veterans Integrated Service Network 

VA OIG Office of Healthcare Inspections 
CAP Review of the Boise VA Medical Center, Boise, ID 

Table of Contents 

Page
 

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

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

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

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

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

Results ........................................................................................................................ 3
 

Review Activities with Recommendations............................................................... 3
 

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

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

EOC................................................................................................................... 4
 

COC .................................................................................................................. 4
 

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

Contract CNH Program ..................................................................................... 5
 

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

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

Medication Management ................................................................................... 6
 

Comments................................................................................................................... 6
 

Appendixes 

A. Facility Profile .................................................................................................... 7
 

B. Follow-Up on Previous Recommendations........................................................ 8
 

C. VHA Satisfaction Surveys and Hospital Outcome of Care Measures................ 10
 

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

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

F. OIG Contact and Staff Acknowledgments ......................................................... 17
 

G. Report Distribution ............................................................................................ 18
 

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

Review of the Boise VA Medical Center, Boise, ID 

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 

October 18, 2010. 

Review Results: The review covered 

seven activities and one follow-up 

review area. We made no 

recommendations in the following 

activities: 

 Management of Test Results 

 Medication Management 

The facility’s reported accomplishments 

included Health Care for Homeless 

Veterans Program successes and an 

Observer Policy that ensures patient 

care and privacy conform to VA 

standards. 

Recommendations: We made 

recommendations in the following five 

activities and in the follow-up review 

area: 

Quality Management: All areas 

performing moderate sedation need to 

monitor documentation to ensure 

completeness. 

Physician Credentialing and Privileging: 

Medical Executive Committee meeting 

minutes need to consistently include the 

documents reviewed and the rationale 

for the reprivileging decision. 

Environment of Care: Multi-dose 

medications need to be dated when 

opened. Annual N95 respirator fit 

testing needs to be completed and 

documented. 

Coordination of Care: A process for 

notifying patients regarding advance 

directives needs to developed and 

implemented. 

Management of Multidrug-Resistant 

Organisms: Infection strategies 

education needs to be provided to 

patients infected or colonized with 

multidrug-resistant organisms and their 

families, and the education needs to be 

documented. 

Contract Community Nursing Home 

Program: Social workers need to 

provide the required visits to patients in 

community nursing homes. 

Comments 

The Veterans Integrated Service 

Network and Acting 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 Boise VA Medical Center, Boise, ID 

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 

	 Contract CNH Program 

	 EOC 

	 Management of MDRO 

	 Management of Test Results 

	 Medication Management 

	 Physician C&P 

	 QM 

The review covered facility operations for FY 2009 and 

FY 2010 through October 21, 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 VA Boise Medical Center, Boise, Idaho, 

VA OIG Office of Healthcare Inspections 1 
CAP Review of the Boise VA Medical Center, Boise, ID 

Report No. 06-02002-233, September 29, 2006). The facility 

had corrected all prior findings. However, during this review, 

we identified a finding related to a prior finding in the area of 

Contract CNH Program monthly visits. 

During this review, we also presented crime awareness 

briefings for 193 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 

In October 2010, the facility was selected as one of 16 sites 

nationally to participate in VA’s 5-year plan to end 

homelessness. VA based the selection on the facility’s 

highly successful HCHV program and will provide the facility 

with additional financial support in FY 2011 to develop new 

initiatives. The HCHV program currently consists of 

60 transitional beds, 90 permanent housing units, and 

6 emergency beds and offers a full continuum of housing 

services for veterans. In addition, the facility has established 

multiple community partnerships that provide additional 

transitional housing beds and funds to assist with move-in 

expenses. The distribution of housing vouchers through the 

U.S. Department of Housing and Urban Development and 

VA’s Supportive Housing Program has increased the number 

of veterans who successfully obtain resident status. In 

September 2010, the facility exceeded its target rate of 

73 percent by providing housing to 95 percent of its veterans 

who needed assistance. 

The facility implemented the Observer Policy to establish 

procedures for physician researchers, physician guests, and 

clinical observers to ensure that the facility conforms to VA 

standards for patient care and privacy. The facility also 

implemented an electronic monitoring system to supervise 

resident physician documentation. As a result, all resident 

electronic note entries are reviewed by physicians, which 

provides residents, residency coordinators, and attendees 

with ongoing feedback. 

HCHV Program 

Recognition 

Observer Policy 

and Resident 

Documentation 

VA OIG Office of Healthcare Inspections 2 
CAP Review of the Boise VA Medical Center, Boise, ID 

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. The QM program was generally compliant with 

requirements, and senior managers supported the program. 

However, we identified the following area that needed 

improvement. 

Moderate Sedation. VHA requires facilities to assess and 

monitor patients undergoing moderate sedation.1 We 

reviewed the medical records of 10 patients who underwent 

moderate sedation and found documentation deficiencies in 

3 (30 percent) of the records. Missing elements included 

immediate assessment prior to sedation and physical 

assessment. 

Recommendation	 1. We recommended that all areas performing moderate 

sedation monitor documentation to ensure completeness. 

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 area that needed improvement. 

Reprivileging. VHA requires that requested privileges be 

presented to the MEC for review along with the supporting 

clinical competence information and that the documents 

reviewed and the rationale for the reprivileging decision be 

documented in the meeting minutes.2 MEC meeting minutes 

did not include the required documentation for 5 (36 percent) 

of the 14 physicians’ reviewed. 

1 VHA Directive 2006-023, Moderate Sedation by Non-Anesthesia Providers, May 1, 2006. 2 VHA Handbook 1100.19, Credentialing and Privileging, November 14, 2008. 

VA OIG Office of Healthcare Inspections 3 
CAP Review of the Boise VA Medical Center, Boise, ID 

Recommendation 

EOC 

Recommendations 

COC 

2. We recommended that MEC meeting minutes 

consistently include the documents reviewed and the 

rationale for the reprivileging decision. 

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 medical/surgical, intensive care, MH, and 

CLC inpatient units; the eye and dental outpatient clinics; 

and the ED. The facility maintained a generally clean and 

safe environment. However, we identified the following 

areas that needed improvement. 

Medication Security. Local policy requires that multi-dose 

medication vials be dated when opened. We found eight 

open and undated multi-dose medication vials—seven in the 

eye clinic and one on the medical/surgical unit. 

N95 Respirator Fit Testing. CDC guidelines recommend that 

all health care personnel entering rooms of patients with 

confirmed, suspected, or probable swine flu should wear, at 

a minimum, a fit tested N95 respirator. In addition, OSHA 

standards require designated staff to be fit tested and trained 

for respirator use as part of a complete respiratory protection 

program. We reviewed training records of 21 employees and 

determined that 5 (24 percent) employees had not received 

the required annual fit testing. 

3. We recommended that multi-dose medications be dated 

when opened, as required by local policy. 

4. We recommended that annual N95 respirator fit testing 

be completed and documented. 

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 found the discharge process to be in 

compliance with VHA policy. However, we identified the 

following area that needed improvement. 

VA OIG Office of Healthcare Inspections 4 
CAP Review of the Boise VA Medical Center, Boise, ID 

Recommendation 

Management of 

MDRO 

Recommendation 

Contract CNH 

Program 

Written Notification Review. VHA requires3 that patients be 

given written notification stating their right to accept or refuse 

medical treatment, to designate an HCA, and to document 

their treatment preferences in an advance directive. In 

addition, patients must be informed that VA does not 

discriminate against patients based on whether or not they 

have an advance directive. We reviewed advance care 

planning documentation for 10 patients and determined that 

the facility had not implemented a process to provide written 

notification. At the time of this review, a facility team had 

been organized to correct this deficiency. 

5. We recommended that a process for notifying patients 

regarding advance directives be developed and 

implemented. 

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 medical/surgical inpatient units and the 

CLC units and interviewed 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 colonized4 with MDRO and their families receive 

education on infection reduction strategies, such as hand 

washing and the proper use of PPE. We reviewed 

30 medical records and found that 8 (27 percent) of the 

records did not have documented evidence of MDRO 

education. 

6. We recommended that infection strategies education be 

provided to patients infected or colonized with MDRO and 

their families and that the education be documented. 

The prior CAP review findings regarding the Contract CNH 

Program were corrected. However, we identified a related 

finding. 

Monthly Visits. VHA policy requires an SW or RN to 

alternately visit each VA patient in a CNH at least every 

30 days unless otherwise indicated by the patient’s treatment 

3 VHA Handbook 1004.02, Advance Care Planning and Management of Advance Directives, July 2, 2009. 4 Colonization is the presence of bacteria in the body without causing clinical infection. 

VA OIG Office of Healthcare Inspections 5 
CAP Review of the Boise VA Medical Center, Boise, ID 

plan.5 These follow-up visits are necessary to ensure that 

treatment goals are being met and that the patient care 

provided is appropriate. We reviewed 10 medical records 

(timeframe of August 2009 through September 2010) and 

found that SWs did not consistently document the required 

monthly visits in 2 (20 percent) of the records. 

Recommendation	 7. We recommended that SWs provide the required visits to 

patients in CNHs. 

Review Activities Without Recommendations 

Management of 

Test Results 

Medication 

Management 

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

review that identified improvement opportunities related to 

documentation of notification of abnormal test results and 

follow-up actions taken.6 

We reviewed the facility’s policies and procedures, the 

process for monitoring communication of test results, and the 

medical records of patients who had tests resulting in critical 

values and normal values. We determined that the facility 

had implemented an effective reporting process for test 

results. We made no recommendations. 

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 Acting Facility Directors agreed with the CAP review findings and 

recommendations and provided acceptable improvement plans. (See Appendixes 

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

the planned actions until they are completed. 

5 VHA Handbook 1143.2, VHA Community Nursing Home Oversight Procedures, June 4, 2004. 6 Healthcare Inspection Summary Review – Evaluation of Veterans Health Administration Procedures for 

Communicating Abnormal Test Results, Report No. 01-01965-24, November 25, 2002. 

VA OIG Office of Healthcare Inspections 6 
CAP Review of the Boise VA Medical Center, Boise, ID 

Appendix A 

Facility Profile7 

Type of Organization Primary and secondary medical center with 

some tertiary services 

Complexity Level 2 

VISN 20 

CBOCs Caldwell, ID 

Twin Falls, ID 

Veteran Population in Catchment Area 98,000 

Type and Number of Total Operating Beds: 

 Hospital, including PRRTP 55 

 CLC/Nursing Home Care Unit 24 

Medical School Affiliation(s) University of Washington 

 Number of Residents 18 

Current FY (through 

June 2010) 

Prior FY (2009) 

Resources (in millions): 

 Total Medical Care Budget $152.7 $134.7 

 Medical Care Expenditures $160 $142 

Total Medical Care FTE 980 900 

Workload: 

 Number of Station Level Unique 

Patients 

23,198 22,170 

 Inpatient Days of Care: 

o Acute Care 10,995 13,112 

o CLC/Nursing Home Care Unit 6,659 5,710 

Hospital Discharges 2,665 3,324 

Total Average Daily Census (including all bed 

types) 

65 66 

Cumulative Occupancy Rate 82 percent 76 percent 

Outpatient Visits 213,565 213,736 

7 All data provided by facility management. 

VA OIG Office of Healthcare Inspections 7 
CAP Review of the Boise VA Medical Center, Boise, ID 

Appendix B 

Follow-Up on Previous Recommendations 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

QM 

1. Fully inform patients who experience 

adverse events, and document the 

discussions. 

Adverse events are disclosed to 

patients as required. 

Y N 

2. Provide detailed analyses of UM data. Detailed analyses of UM data is 

provided by the Utilization Coordinator. 

Y N 

3. Act on results that do not meet goals. Results that do not meet goals are 

acted on in a discussion forum. 

Y N 

EOC 

4. Secure patient information, hard copy or 

visible on computer screens. 

Patient information is secured by 

locking equipment and privacy shields 

for computer monitors. 

Y N 

5. Comply with fire safety requirements for 

storage areas. 

Storage areas are routinely monitored 

for compliance during EOC rounds. 

Y N 

Contract CNH Program 

6. Develop individualized plans for 

follow-up visits prior to placement of patients 

in CNHs. 

Individualized plans and follow-up visit 

schedules are developed. 

Y N 

7. Provide the required RN visits. RNs provide the required visits. Y N 

8. Integrate the CNH program into the QM 

program. 

Results of the Quality Assurance 

Surveillance Plan, including CNH 

oversight, are reported to the MEC 

annually. 

Y N 

9. Create a CNH Oversight Committee with 

the appropriate membership. 

CNH Oversight Committee with 

appropriate membership was created. 

Y N 

VA OIG Office of Healthcare Inspections 8 
CAP Review of the Boise VA Medical Center, Boise, ID 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

10. Contact the State Ombudsman’s office 

annually to discuss issues relevant to the 

CNH program. 

CNH Coordinator contacts the State 

Ombudsman’s office annually. 

Y N 

Breast Cancer Management 

11. Take action to improve compliance with 

VHA’s breast cancer screening performance 

measure. 

The facility Breast Cancer Screening 

PM score of 85 percent in FY 2010 

exceeded the target of 72 percent. 

Y N 

VA OIG Office of Healthcare Inspections 9 
CAP Review of the Boise VA Medical Center, Boise, ID 

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 71.8 64.0 81.7 64.4 57.5 60.5 

VISN 61.2 65.7 68.8 49.6 49.7 50.0 

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 10 
CAP Review of the Boise VA Medical Center, Boise, ID 

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

conditions8 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 13.77 9.26 13.72 20.73 23.5 14.44 

VHA 13.31 9.73 15.08 20.57 21.71 15.85 

8 CHF is a weakening of the heart’s pumping power. With heart failure, the 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 may become damaged from lack of oxygen. Pneumonia is a serious 

lung infection that fills lungs with mucus and causes difficulty in breathing, fever, cough, and fatigue. 

VA OIG Office of Healthcare Inspections 11 
CAP Review of the Boise VA Medical Center, Boise, ID 

Appendix D 

VISN Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: December 9, 2010 

From: Director, Northwest Network (10N20) 

Subject: CAP Review of the Boise VA Medical Center, Boise, ID 

To: Director, Denver Office of Healthcare Inspections (54DV) 

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

1.	 Thank you for the opportunity to provide a review of the draft OIG 

Report of the Combined Assessment Program Review of the Boise VA 

Medical Center, Boise, Idaho. 

2.	 Attached, please find the facility concurrences and responses to each 

of the findings from the review conducted the week of 

October 18, 2010. 

3.	 If you have additional questions or need further information, please 

contact Nancy Benton, Quality Management Officer, VISN 20 at 

(360) 619-5949 or Susan Gilbert, Survey Coordinator, VISN 20 at 

(360)-567-4678. 

Susan Pendergrass, DrPH
 

Director, Northwest Network (10N20)
 

VA OIG Office of Healthcare Inspections 12 
CAP Review of the Boise VA Medical Center, Boise, ID 

Appendix E 

Acting Facility Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: December 9, 2010 

From: Acting Director, Boise VA Medical Center (531/00) 

Subject: CAP Review of the Boise VA Medical Center, Boise, ID 

To: Director, Northwest Network (10N20) 

1.	 I would like to express my sincere appreciation to the OIG CAP review 

team for their professionalism and consultative feedback to our 

employees during our review. 

2.	 I have reviewed the recommendations and concur with the findings. 

Our comments and planned actions are outlined below. 

3.	 If you have questions or require additional information, please do not 

hesitate to contact Jan Gieselman, Accreditation Manager, at 

(208) 422-1000, Extension 7000. 

Grant Ragsdale 

Acting Director, Boise VA Medical Center 

VA OIG Office of Healthcare Inspections 13 
CAP Review of the Boise VA Medical Center, Boise, ID 

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 all areas performing moderate sedation 

monitor documentation to ensure completeness. 

Concur 

Target date for completion: Completed December 7, 2010 

The OIG CAP Team noted that not all areas performing moderate sedation were 

included in the current moderate sedation monitor being performed by the organization. 

To address this, the organization has adjusted the moderate sedation monitor to include 

a representative sample of cases from all areas performing moderate sedation (ICU, 

ED, GI Endoscopy, and Bronchoscopy) to create a total sample size of 70 Moderate 

Sedation records quarterly. The monitor includes review for documented physical 

assessment and reassessment immediately prior to sedation. The monitor plan 

provides for submission of results to the Moderate Sedation Provider’s Service Chief for 

incorporation into provider OPPE data. 

Recommendation 2. We recommended that MEC meeting minutes consistently 

include the documents reviewed and the rationale for the reprivileging decision. 

Concur 

Target date for completion: The templates will be initiated at the December 16, 2010 

MEC meeting. 

A report template has been developed for the Service Chief to use when presenting 

criteria for reprivileging to MEC. The report template reminds the Service Chief to 

discuss documents reviewed and the rationale for the privileges being requested. A 

companion template has been developed for the MEC Credentialing/Privileging minutes 

that includes fields to incorporate supporting clinical competence information and the 

rationale for the reprivileging decision. The use of these two templates will assure that 

the required elements are presented during the reprivileging session and are 

documented in the minutes. 

VA OIG Office of Healthcare Inspections 14 
CAP Review of the Boise VA Medical Center, Boise, ID 

Recommendation 3. We recommended that multi-dose medications be dated when 

opened, as required by local policy. 

Concur 

Target date for completion: December 8, 2010 audit results indicate 100 percent 

compliance. We anticipate continued 90 percent or greater compliance through 

March 31, 2011. 

To address this finding, Pharmacy re-educated staff of the Eye Clinic and 2MS to the 

facility multidose labeling process and verified that a current supply of the standard 

labels were available for staff use. A monthly audit has been implemented to identify 

any opened mutidose vials that are not dated and labeled in accordance with facility 

policy. Audit results are reported by Pharmacy to the Quality Oversight Council until 

4 consecutive months of 90 percent or greater compliance is achieved. 

Recommendation 4. We recommended that annual N95 respirator fit testing be 

completed and documented. 

Concur. All personnel who need protection from exposure to respiratory hazards (per 

OSHA Respiratory Protection Program Guidelines) will be fit tested and trained in the 

proper use and care of a respirator upon hire and annually thereafter, in accordance 

with OSHA regulations. 

Target date for completion: March 31, 2011, for all delinquent staff to complete annual 

respirator fit-testing and training, with a documented record of completion. 

1. The Industrial Hygienist has notified all employees (and their supervisor) who are 

delinquent for their annual fit-testing and training. 

2. The Industrial Hygienist utilizes OSHA-compliant protocols to complete the annual 

fit-testing and training required of the facility respiratory protection program. 

3. Completion of mandatory fit-testing and training is documented using facility tracking 

systems. 

4. Compliance reports are given to the Environment of Care Committee monthly until 

90 percent or greater compliance is achieved (anticipate closure by March 31, 2011). 

To assure sustained performance, the Industrial Hygienist will provide ongoing quarterly 

compliance reports for respirator fit-testing and training to the Environment of Care 

Committee. The Environment of Care Committee takes action for non-compliance. 

Recommendation 5. We recommended that a process for notifying patients regarding 

advance directives be developed and implemented. 

Concur 

Target date for completion: Completed December 6, 2010. 

VA OIG Office of Healthcare Inspections 15 
CAP Review of the Boise VA Medical Center, Boise, ID 

An ad hoc team of the Integrated Ethics Committee has developed a process for 

notifying patients regarding advance directives. VA form 10-0137A, “Your Rights 

Regarding Advance Directives,” has been incorporated into the admission packets for 

the medical center. Documentation templates have been amended to facilitate 

documentation of the provision of notification related to advance directives into the 

medical record. Staff have been educated to the notification process and the 

documentation template revisions. Compliance with the Advance Directive notification 

process is now a part of the facility Medical Record Review process. 

Recommendation 6. We recommended that infection strategies education be provided 

to patients infected or colonized with MDRO and their families and that the education be 

documented. 

Concur 

Target date for completion: We anticipate 90 percent or greater compliance by 

March 30, 2011. 

Staff have been educated to the need to provide infection strategies education to 

patients the families of patients infected or colonized with MDRO. Educational 

pamphlets are widely available throughout the medical center. A monitor has been 

established to review 30 records (or 100 percent if less than 30) of patients newly 

identified as infected or colonized with MDROs monthly for documentation of MDRO 

infection control education. Results are reported to Infection Control Committee 

monthly until 90 percent or greater compliance is achieved for 4 consecutive months. 

Results will then be reported quarterly for the remainder of FY11, at which time the 

need to continue the monitor will be re-evaluated. The Infection Control Committee will 

take action whenever there is reported compliance of less than 90 percent. 

Recommendation 7. We recommended that SWs provide the required visits to 

patients in CNHs. 

Concur 

Target date for completion: We anticipate 4 consecutive months of compliance by 

February 28, 2011. 

The CNH staff have been re-educated to the handbook requirement for SW or RN to 

visit each VA patient in a CNH every 30 days unless otherwise indicated by the patient’s 

treatment plan. The Chair of the CNH Oversight Committee monitors 30 records (or 

100 percent if less than 30) monthly for documentation of the required CNH RN or SW 

visit. Results are reported to the Quality Oversight Council until 100 percent compliance 

is achieved for 4 consecutive months. Results will be monitored and reported quarterly 

(on an ongoing basis) to the CNH Oversight Committee to assure sustained 

compliance. The November 2010 audit indicated that 100 percent (35/35) of required 

RN or SW visits were completed. 

VA OIG Office of Healthcare Inspections 16 
CAP Review of the Boise VA Medical Center, Boise, ID 

Appendix F 

OIG Contact and Staff Acknowledgments 

Contact Virginia L. Solana, Director, RN, MA 

Denver Office of Healthcare Inspections 

Contributors Clarissa B. Reynolds, CNHA, Team Leader 

Sheila J. Bezak, MBI 

Katharine L. Foster, RN, BSN 

Stephanie B. Hensel, JD, MPA, BSN 

Barry L. Simon, VMD 

Ann Ver Linden, RN, BSN 

Cheryl A. Walker, MSN, FNP-C 

Laura L. Dulcie, BSEE 

Darrin Gilbert, Resident Agent in Charge, Office of Investigations 

Report Produced under the direction of Virginia L. Solana 

Preparation Director, Denver Office of Healthcare Inspections 

VA OIG Office of Healthcare Inspections 17 
CAP Review of the Boise VA Medical Center, Boise, ID 

Appendix G 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, Northwest Network (10N20) 

Director, Boise VA Medical Center (531/00) 

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: Mike Crapo, James E. Risch 

U.S. House of Representatives: Raul Labrador, Mike Simpson 

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

VA OIG Office of Healthcare Inspections 18