Department of Veterans Affairs 

Office of Inspector General 

Office of Healthcare Inspections
 

Report No. 10-03091-88 

Combined Assessment Program
 

Review of the
 

Ralph H. Johnson VA Medical Center
 

Charleston, South Carolina
 

February 14, 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 Ralph H. Johnson VA Medical Center, Charleston, SC 

Glossary 

C&P credentialing and privileging 

CAP Combined Assessment Program 

CBOC community based outpatient clinic 

CEB Clinical Executive Board 

CHF congestive heart failure 

CLC community living center 

COC coordination of care 

CT computed tomography 

EOC environment of care 

ER emergency room 

facility Ralph H. Johnson VA Medical Center 

FTE full-time employee equivalents 

FY fiscal year 

IC infection control 

JC Joint Commission 

MDRO multidrug-resistant organisms 

MH mental health 

NUMI National Utilization Management Integration 

OIG Office of Inspector General 

PIC Performance Improvement Committee 

PRC Peer Review Committee 

PRRTP Psychosocial Residential Rehabilitation Treatment 

Program 

PUMA physician utilization management advisor 

QM quality management 

RCA root cause analysis 

SOPs standard operating procedures 

UM utilization management 

VHA Veterans Health Administration 

VISN Veterans Integrated Service Network 

VA OIG Office of Healthcare Inspections 
CAP Review of the Ralph H. Johnson VA Medical Center, Charleston, SC 

Table of Contents 

Page
 

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

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

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

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

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

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

Management of MDRO...................................................................................... 2
 

Management of Test Results ............................................................................ 3
 

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

Review Activities Without Recommendations ......................................................... 4
 

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

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

Medication Management ................................................................................... 4
 

Physician C&P................................................................................................... 4
 

Comments................................................................................................................... 5
 

Appendixes 

A. Facility Profile .................................................................................................... 6
 

B. Follow-Up on Previous Recommendations........................................................ 7
 

C. VHA Satisfaction Surveys and Hospital Outcome of Care Measures................ 9
 

D. Acting VISN Director Comments ....................................................................... 11
 

E. Facility Director Comments ............................................................................... 12
 

F. OIG Contact and Staff Acknowledgments ......................................................... 14
 

G. Report Distribution ............................................................................................ 15
 

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

Review of the Ralph H. Johnson VA Medical Center, 

Charleston, SC 

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 6, 2010. 

Review Results: The review covered 

seven activities. We made no 

recommendations in the following 

activities: 

	 Coordination of Care 

	 Environment of Care 

	 Medication Management 

	 Physician Credentialing and 

Privileging 

Recommendations: We made 

recommendations in the following three 

activities: 

Management of Multidrug-Resistant 

Organisms: Ensure employees receive 

annual multidrug-resistant organism 

education and that the training is 

consistently documented. 

Management of Test Results: Ensure 

normal test results are communicated to 

patients within the specified timeframe. 

Quality Management: Ensure 

medical record reviews include 

unsigned/uncosigned progress notes 

and addenda. 

Comments 

The Acting 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 Ralph H. Johnson VA Medical Center, Charleston, SC 

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 December 6, 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 Ralph H. Johnson VA Medical Center, 

VA OIG Office of Healthcare Inspections 1 
CAP Review of the Ralph H. Johnson VA Medical Center, Charleston, SC 

Charleston, South Carolina, Report No. 08-00529-112, 

April 14, 2008). The facility had corrected all findings. (See 

Appendix B for further details.) 

During this review, we also presented crime awareness 

briefings for 209 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 

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 reviewed the facility’s IC risk assessment, employee 

training records, and medical records. We inspected the 

medical (3BN and 3BS) and medical/surgical (4BN) units and 

interviewed employees. We did not identify any deficits in 

either the inspections or staff interviews. However, we 

identified the following area that needed improvement. 

Employee Training. The JC requires that facilities conduct a 

risk assessment to determine the need for staff education on 

MDRO. The facility’s most recent risk assessment stated 

that staff education was indicated for all employees during 

orientation and annually thereafter. We reviewed 

29 employee training records to determine whether MDRO 

education had been provided in accordance with the risk 

assessment. We found that only 23 (79 percent) of the 

records reviewed had documentation of annual MDRO 

education. 

1. We recommended that employees receive annual 

MDRO education and that the training is consistently 

documented. 

Management of 

MDRO 

Recommendation 

VA OIG Office of Healthcare Inspections 2 
CAP Review of the Ralph H. Johnson VA Medical Center, Charleston, SC 

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.1 

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.2 We reviewed the medical 

records of 20 outpatients who had normal results and found 

that only 10 (50 percent) of the 20 records contained 

documented evidence that the facility had communicated the 

results to the patients within the specified timeframe. 

Recommendation	 2. We recommended that normal test results be 

consistently communicated to patients within the specified 

timeframe. 

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 area that needed 

improvement. 

Medical Record Reviews. VHA requires facilities to conduct 

medical record reviews that include specific components.3 

While medical record reviews had been completed, we found 

that they did not include all of the required components. We 

found that the facility did not include reviews of 

unsigned/uncosigned progress notes and addenda, as 

required. 

Recommendation	 3. We recommended that medical record reviews include 

unsigned/uncosigned progress notes and addenda. 

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

Communicating Abnormal Test Results, Report No. 01-01965-24, November 25, 2002.
 2 VHA Directive 2009-019, Ordering and Reporting Test Results, March 24, 2009.
 3 VHA Handbook 1907.01, Health Information Management and Health Records, August 25, 2006.
 

VA OIG Office of Healthcare Inspections 3 
CAP Review of the Ralph H. Johnson VA Medical Center, Charleston, SC 

Review Activities Without Recommendations 

COC
 

EOC 

Medication 

Management 

Physician C&P 

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 20 patients’ medical records and determined 

that the facility generally met requirements in these areas. 

We made no recommendations. 

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 (3BN and 3BS), medical/surgical 

(4BN), surgical intensive care, medical intensive care, and 

MH units; the bronchoscopy/urology procedure room; the 

urology and primary care clinics; the ER; and the CLC. We 

also inspected ultrasound, CT, and interventional and 

general radiology. The facility maintained a generally clean 

and safe environment. 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. 

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. 

VA OIG Office of Healthcare Inspections 4 
CAP Review of the Ralph H. Johnson VA Medical Center, Charleston, SC 

Comments 

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

recommendations and provided acceptable improvement plans. (See Appendixes D 

and E, pages 11–13, 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 5 
CAP Review of the Ralph H. Johnson VA Medical Center, Charleston, SC 

Appendix A 

Facility Profile4 

Type of Organization Tertiary care medical center 

Complexity Level 1c 

VISN 7 

CBOCs Myrtle Beach, SC 

Goose Creek, SC 

Beaufort, SC 

Savannah, GA 

Veteran Population in Catchment Area 177,332 

Type and Number of Total Operating Beds: 

 Hospital, including PRRTP 98 

 CLC/Nursing Home Care Unit 20 

 Other N/A 

Medical School Affiliation(s) The Medical University of South Carolina, 

Charleston, SC 

 Number of Residents 82 medical and 2 dental 

Current FY (through 

October 2011) 

Prior FY (2010) 

Resources (in millions): 

 Total Medical Care Budget $278.2 $267.3 

 Medical Care Expenditures N/A $266.3 

Total Medical Care FTE 1,484 1,465 

Workload: 

 Number of Station Level Unique 

Patients 

Data not available 50,240 

 Inpatient Days of Care: 

o Acute Care 1,894 24,171 

o CLC/Nursing Home Care Unit 492 6,704 

Hospital Discharges 372 4,721 

Total Average Daily Census (including all bed 

types) 

87 91 

Cumulative Occupancy Rate (all bed types) 73.6% 72.2% 

Outpatient Visits Data not available 602,048 

4 All data provided by facility management. 

VA OIG Office of Healthcare Inspections 6 
CAP Review of the Ralph H. Johnson VA Medical Center, Charleston, SC 

Appendix B 

Follow-Up on Previous Recommendations 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

QM 

1. Complete peer reviews timely, document 

rationales for peer review level changes, and 

present trending analysis data to the CEB 

and the PIC. 

Minutes reflect documentation of 

rationales for peer review decisions. 

Data is presented quarterly to the CEB. 

The facility PIC underwent 

organizational changes, and the PRC 

reports to the CEB and executive 

leadership. 

Y N 

2. Ensure clear processes are in place to 

adequately evaluate events that could 

potentially require disclosure. 

The PRC evaluates events for potential 

disclosure and documents in PRC 

minutes. 

Y N 

3. Complete RCAs timely. RCAs are meeting timeliness 

standards. 

Y N 

4. Ensure UM processes comply with VHA 

policy. 

UM processes are in compliance with 

VHA policy. One exception is that 

NUMI does not yet support PUMA 

compliance. This is a national issue. 

Y N 

5. Include copying and pasting of notes in 

medical record reviews. 

Facility policy was updated to include 

copy/paste requirements. The Medical 

Record Review Committee conducts 

quarterly reviews. 

Y N 

VA OIG Office of Healthcare Inspections 7 
CAP Review of the Ralph H. Johnson VA Medical Center, Charleston, SC 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

Patient Satisfaction 

6. Implement an action plan to improve 

patient satisfaction that includes measurable 

goals and assigns responsibility for 

completion of tasks. 

Patient satisfaction is a high-priority 

goal. A Patient Family Centered Care 

Committee was convened to address 

patient satisfaction. In addition, 

services report at the weekly 

leadership meeting on their action 

plans for improvement. 

Y N 

Electronic Medical Record Business Rules 

7. Ensure compliance with VHA Handbook 

1907.01 and October 2004 Office of 

Information guidance related to electronic 

medical records. 

The business rules are monitored 

centrally by the Office of Information 

and Technology to ensure compliance. 

Y N 

VA OIG Office of Healthcare Inspections 8 
CAP Review of the Ralph H. Johnson VA Medical Center, Charleston, SC 

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 77.2 67.7 73.0 49.1 53.8 51.8 

VISN 67.6 63.8 68.3 52.7 51.7 52.2 

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. 

VA OIG Office of Healthcare Inspections 9 
CAP Review of the Ralph H. Johnson VA Medical Center, Charleston, SC 

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

conditions6 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 13.82 9.82 15.11 19.34 22.38 15.92 

VHA 13.31 9.73 15.08 20.57 21.71 15.85 

6 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 10 
CAP Review of the Ralph H. Johnson VA Medical Center, Charleston, SC 

Appendix D 

Acting VISN Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: January 31, 2011 

From: Acting Director, VA Southeast Network, VISN 7 (10N7) 

Subject: CAP Review of the Ralph H. Johnson VA Medical Center, 

Charleston, SC 

To: Director, Atlanta Office of Healthcare Inspections Division 

(54AT) 

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

I fully concur and support the recommendations and action plans target 

date for completion. 

(original signed by:) 

J. Mark Anderson, FACHE 

VA OIG Office of Healthcare Inspections 11 
CAP Review of the Ralph H. Johnson VA Medical Center, Charleston, SC 

Appendix E 

Facility Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: January 27, 2011
 

From: Director, Ralph H. Johnson VA Medical Center (534/00)
 

Subject: CAP Review of the Ralph H. Johnson VA Medical Center,
 

Charleston, SC 

To: Director, VA Southeast Network (10N7) 

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

Assessment Program (CAP) of the Ralph H. Johnson VA Medical Center. 

We concur with the findings and recommendations. 

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

improve the care to our veterans. 

(original signed by Scott Isaacks, Associate Director for:) 

CAROLYN L. ADAMS 

VA OIG Office of Healthcare Inspections 12 
CAP Review of the Ralph H. Johnson VA Medical Center, Charleston, SC 

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 employees receive annual MDRO 

education and that the training is consistently documented. 

Concur 

Target date for completion: March 31, 2011 

The education and training plan has been updated to ensure all designated employees 

receive the training annually. 

Recommendation 2. We recommended that normal test results be consistently 

communicated to patients within the specified timeframe. 

Concur 

Target date for completion: May 1, 2011 

The facility processes have been reviewed and plans for improvement are being 

developed with the Clinical Leaders. To facilitate notification of normal radiology test 

results, communications have been initiated with the project manager for VISTA RAD to 

determine capabilities of generating patient letters from the dictation system. Once 

processes are defined, the results will be audited by QM and the Medical Records 

Review Committee to ensure compliance. 

Recommendation 3. We recommended that medical record reviews include 

unsigned/uncosigned progress notes and addenda. 

Concur 

Target date for completion: March 1, 2011 

A plan for improvement has been developed and will be presented to the Medical 

Records Review Committee in February for approval and implementation. 

VA OIG Office of Healthcare Inspections 13 
CAP Review of the Ralph H. Johnson VA Medical Center, Charleston, SC 

Appendix F 

OIG Contact and Staff Acknowledgments 

Contact Toni Woodard, Project Leader 

Atlanta Office of Healthcare Inspections 

Contributors Karen Sutton, Team Leader 

Victoria Coates 

Tishanna McCutchen 

Susan Zarter 

Paul Lee, Columbia Office of Investigations 

VA OIG Office of Healthcare Inspections 14 
CAP Review of the Ralph H. Johnson VA Medical Center, Charleston, SC 

Appendix G 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Acting Director, VA Southeast Network (10N7) 

Director, Ralph H. Johnson VA Medical Center (534/00) 

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: Jim DeMint, Lindsey Graham 

U.S. House of Representatives: James E. Clyburn, Jeff Duncan, Trey Gowdy, 

Mick Mulvaney, Tim Scott, Joe Wilson 

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

VA OIG Office of Healthcare Inspections 15