Department of Veterans Affairs 

Office of Inspector General 

Office of Healthcare Inspections
 

Report No. 10-02385-62

Combined Assessment Program
 

Review of the
 

Philadelphia VA Medical Center
 

Philadelphia, Pennsylvania
 

January 13, 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 Philadelphia VA Medical Center, Philadelphia, PA 

Glossary 

AAMI Association for the Advancement of Medical 

Instrumentation 

ANSI American National Standards Institute 

C&P credentialing and privileging 

CAP Combined Assessment Program 

CBOC community based outpatient clinic 

CLC community living center 

COC coordination of care 

EOC environment of care 

facility Philadelphia VA Medical Center 

FY fiscal year 

GU genitourinary 

IC infection control 

MH mental health 

MRI magnetic resonance imaging 

MSIT Multidisciplinary Safety Inspection Team 

NFPA National Fire Protection Association 

NUMI National Utilization Management Integration 

OIG Office of Inspector General 

OPPE Ongoing Professional Practice Evaluation 

OR operating room 

OSHA Occupational Safety and Health Administration 

PPE personal protective equipment 

PR peer review 

QM quality management 

RME reusable medical equipment 

SBAR Situation, Background, Assessment, 

Recommendation 

SHEP Survey of Healthcare Experiences of Patients 

SOPs standard operating procedures 

SPD Supply, Processing, and Distribution 

TJC The Joint Commission 

UM utilization management 

VHA Veterans Health Administration 

VISN Veterans Integrated Service Network 

VA OIG Office of Healthcare Inspections 
CAP Review of the Philadelphia VA Medical Center, Philadelphia, PA 

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................................................................................................... 4
 

RME .................................................................................................................. 5
 

EOC................................................................................................................... 7
 

MRI Safety......................................................................................................... 10
 

Review Activities Without Recommendations ......................................................... 11
 

COC .................................................................................................................. 11
 

Medication Management ................................................................................... 12
 

Suicide Prevention Safety Plans........................................................................ 12
 

Comments................................................................................................................... 13
 

Appendixes 

A. Facility Profile .................................................................................................... 14
 

B. Follow-Up on Previous Recommendations........................................................ 15
 

C. VHA Satisfaction Surveys and Hospital Outcome of Care Measures................ 17
 

D. VISN Director Comments .................................................................................. 19
 

E. Facility Director Comments ............................................................................... 20
 

F. OIG Contact and Staff Acknowledgments ......................................................... 26
 

G. Report Distribution ............................................................................................ 27
 

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

Review of the Philadelphia VA Medical Center, 

Philadelphia, PA 

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 

September 13, 2010. 

Review Results: The review covered 

eight activities. We made no 

recommendations in the following 

activities: 

 Coordination of Care 

 Medication Management 

 Suicide Prevention Safety Plans 

The facility’s reported accomplishments 

were resident memorials and the use of 

a Behavioral Health Laboratory model. 

Recommendations: We made 

recommendations in the following five 

activities: 

Quality Management: Document action 

plans in committee minutes, request 

peer review extensions in writing, 

comply with policy for reporting patient 

complaint data, and monitor the copy 

and paste functions. 

Physician Credentialing and Privileging: 

Comply with requirements for physician 

privileging. 

Reusable Medical Equipment: Restrict 

access to decontamination areas; 

ensure staff don personal protective 

equipment; and conduct required 

ventilation, air filter, and air exchange 

inspections. Require that standard 

operating procedures be consistent with 

manufacturers’ guidelines and be 

followed. Ensure flash sterilization is 

used in the operating room only in case 

of emergency, and continue monitoring. 

Environment of Care: Address the 

identified environmental hazard. 

Conduct a self-assessment, and take 

corrective actions as necessary. 

Require consistent documentation of 

biological testing. Ensure designated 

staff undergo required annual training. 

Ensure that rounds are attended and 

that attendance is documented. 

Magnetic Resonance Imaging Safety: 

Ensure personnel address positive 

responses on screening questionnaires 

and document actions taken. Require 

referring physicians to document initial 

screenings. Ensure that personnel who 

have access to the area receive the 

appropriate level of safety training and 

that training is documented. 

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 Philadelphia VA Medical Center, Philadelphia, PA 

Objectives and Scope 

Objectives
 

Scope
 

Objectives. 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. 

Scope. 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 eight activities: 

	 COC 

	 EOC 

	 Medication Management 

	 MRI Safety 

	 QM 

	 Physician C&P 

	 RME 

	 Suicide Prevention Safety Plans 

The review covered facility operations for FY 2009 and 

FY 2010 through September 13, 2010, and was done in 

accordance with OIG SOPs for CAP reviews. We also 

followed up on selected recommendations from our prior 

VA OIG Office of Healthcare Inspections 1 
CAP Review of the Philadelphia VA Medical Center, Philadelphia, PA 

CAP review of the facility (Combined Assessment Program 

Review of the Philadelphia VA Medical Center, Philadelphia, 

Pennsylvania, Report No. 07-02498-52, January 4, 2008). 

We identified repeat findings from our prior review in the 

areas of QM committee minutes and EOC rounds 

attendance. 

During this review, we also presented crime awareness 

briefings for 295 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 

Both individual bedside remembrances at the time of a 

resident’s death and quarterly memorial services are held in 

the CLC to celebrate the lives of the deceased, to recognize 

their accomplishments, and to honor their death with dignity. 

The bedside remembrance service includes draping an 

American flag across the bed, playing peaceful music, and 

reciting the poem, Taps. Staff and other residents sign a 

sympathy card that is presented to the family. The 

memorials allow family, staff, and other CLC residents the 

opportunity to share in the bereavement process and to 

create positive, lasting memories. 

The facility developed a model of collaborative care 

management for veterans with MH issues that is consistent 

with the guiding principles of the Patient-Centered Medical 

Home. The program maximizes the use of nursing, 

psychology, or social work staff as care managers while 

retaining the primary care provider at the center of treatment 

planning. The model uses a well-structured screening tool; 

flexible, patient-centered service delivery; evidence-based 

care management protocols; and time-limited interventions. 

The program has been successful in improving patient 

outcomes in specific areas, increasing access, providing 

collaborative assistance to primary care practitioners to 

manage mild to moderate cases, and facilitating specialty 

care referral. The program was recently recognized by the 

American Psychiatric Association as a national best practice. 

CLC Resident 

Memorials 

Behavioral Health 

Lab 

VA OIG Office of Healthcare Inspections 2 
CAP Review of the Philadelphia VA Medical Center, Philadelphia, PA 

Results 

Review Activities With Recommendations 

QM	 The purpose of this review was to evaluate whether the 

facility had a comprehensive QM program designed to 

monitor patient care quality and whether senior managers 

actively supported the program’s activities. 

The QM program was generally effective, and senior 

managers supported the program through participation in 

and evaluation of performance improvement and through the 

allocation of resources to the program. However, we 

identified the following areas that needed improvement. 

QM Committee and Oversight. VHA requires that the QM 

program identify opportunities for improvement, implement 

actions, and evaluate those actions until problems are 

resolved or improvements are achieved.1 We found that 

committee minutes did not consistently identify action plans. 

For example, Medical Executive Committee minutes stated 

that non-disposable tonometers should be replaced without 

identifying an action plan to provide for disposable ones.2 

This is a repeat finding from our previous CAP review. In 

addition, committee minutes did not consistently assign 

responsibility, track open action items, and monitor 

implemented changes. For example, Quality Council 

minutes inappropriately closed items requiring follow-up. 

PR. VHA policy requires facilities to complete a PR within 

120 days.3 Any extension beyond 120 days must be 

requested in writing and approved by the facility’s Director. 

We found that 10 (8 percent) of 118 PRs exceeded 120 days 

without evidence of the required written request and approval 

for extension. 

Patient Complaints. VHA policy requires that facilities report 

patient complaint data quarterly to leadership.4 We found 

that local policy requires biannual reporting and is not 

consistent with VHA policy. 

Medical Record Review. Since 2006, VHA has required that 

facilities have a process for monitoring the copy and paste 

1 VHA Directive 2009-043, Quality Management Systems, September 11, 2009.
 2 A tonometer is an instrument for measuring tension or pressure, particularly pressure within the eye.
 3 VHA Directive 2010-025, Peer Review for Quality Management, June 3, 2010.
 4 VHA Handbook 1003.4, VHA Patient Advocacy Program, September 2, 2005.
 

VA OIG Office of Healthcare Inspections 3 
CAP Review of the Philadelphia VA Medical Center, Philadelphia, PA 

functions in the electronic medical record.5 We identified that 

the facility’s policy was not effective until June 2010, 

and no monitoring took place during FY 2010 through 

September 13, 2010. 

Recommendations	 1. We recommended that committee minutes identify action 

plans, assign responsibility, track open action items, and 

monitor implemented changes. 

2. We recommended that PR extensions be requested in 

writing and approved by the facility’s Director. 

3. We recommended that reporting of patient complaint 

data comply with VHA policy. 

4. We recommended that the facility monitor the copy and 

paste functions in the electronic medical record. 

Physician C&P	 The purpose of this review was to determine whether VHA 

facilities had consistent processes for physician C&P. For a 

sample of physicians, we reviewed selected VHA required 

elements in C&P files and provider profiles. We also 

reviewed meeting minutes during which discussions about 

the physicians took place. 

We reviewed 15 physicians’ C&P files and profiles and found 

that licenses were current and that primary source 

verification had been obtained. Focused Professional 

Practice Evaluation was appropriately implemented for the 

one physician hired within the past 12 months. However, we 

identified the following areas that needed improvement. 

Professional Practice Evaluation. VHA policy and external 

accrediting bodies require a written plan with specific 

competency criteria for all privileged physicians.6 We found 

that the facility had defined privilege-specific criteria for the 

new providers and providers undergoing reprivileging. 

However, we reviewed 6 month’s worth of data to confirm 

privilege-specific competencies and found insufficient OPPE 

information for seven of the nine applicable providers. In 

addition, we found that Credentialing Subcommittee of the 

Medical Executive Committee meeting minutes did not reflect 

discussion of physicians’ performance data. 

5 VHA Handbook 1907.01, Health Information Management and Health Records, August 25, 2006. 6 VHA Handbook 1100.19, Credentialing and Privileging, November 14, 2008. 

VA OIG Office of Healthcare Inspections 4 
CAP Review of the Philadelphia VA Medical Center, Philadelphia, PA 

Physician Privileges. VHA requires that privileges be 

specific to the care setting, such as hospital or clinic.7 We 

found that privileges were setting specific in only 

2 (13 percent) of the 15 C&P files reviewed. For example, a 

surgeon was inappropriately granted privileges to perform 

complex surgery in the outpatient clinics as well as in the 

OR. 

Recommendation	 5. We recommended that all physicians’ profiles include 

sufficient OPPE data and that privileges appropriately 

indicate the setting where they may be practiced. 

RME	 The purpose of this review was to evaluate whether the 

facility had processes in place to ensure effective 

reprocessing of RME. Improper reprocessing of RME may 

transmit pathogens to patients and affect the functionality of 

the equipment. VHA facilities are responsible for minimizing 

patient risk and maintaining a safe environment. The 

facility’s SPD and satellite reprocessing areas are required to 

meet VHA, AAMI, OSHA, and TJC’s standards. 

We inspected the anesthesia, cardiology, ear-nose-throat, 

gastrointestinal, GU, OR, radiology/ultrasound, and SPD 

reprocessing areas. We determined that the facility had 

established appropriate guidelines and monitored 

compliance with those guidelines. Most employees were 

able to either demonstrate the cleaning procedures in the 

SOPs or verbalize the steps. We reviewed the competency 

folders and training records of the employees who 

demonstrated or verbalized the cleaning procedures and 

found that annual competencies were current and 

consistently documented. During our tour of the anesthesia 

decontamination area, we noted that the SOPs were not 

located in the area where reprocessing occurred. This was 

corrected while we were onsite; therefore, we made no 

recommendation for this finding. However, we identified the 

following areas that needed improvement. 

Radiology/Ultrasound Decontamination. VA policy requires 

that traffic in decontamination areas be restricted to 

authorized personnel.8 We found that the reprocessing of 

ultrasound probes in radiology/ultrasound occurred in a 

patient area. The facility self-identified the problem and 

developed an action plan to relocate the reprocessing of 

7 VHA Handbook 1100.19.
 8 VA Handbook 7176; Supply, Processing and Distribution (SPD) Operational Requirements; August 16, 2002.
 

VA OIG Office of Healthcare Inspections 5 
CAP Review of the Philadelphia VA Medical Center, Philadelphia, PA 

ultrasound probes in order to restrict access to authorized 

personnel. 

PPE. VA requires that staff wear PPE at all times while in 

decontamination areas.9 PPE required in this area includes 

gown, gloves, shoe covers, and face mask. We 

observed individuals without appropriate PPE in the 

radiology/ultrasound and GU decontamination areas. 

Ventilation and Airflow. VA requires that Engineering 

Service inspect the ventilation system and air filters at least 

quarterly.10 Facility managers were unable to provide 

documentation of inspections of ventilation systems and air 

filters prior to July 2010 for any of the reprocessing areas 

other than SPD and the OR. 

Additionally, for IC purposes, VA policy requires the use of 

negative ventilation and six air exchanges per hour in 

decontamination areas and the use of positive ventilation in 

clean areas. We found that the GU and radiology/ultrasound 

decontamination areas did not have six air exchanges per 

hour and were not under negative pressure. The GU and 

radiology/ultrasound clean areas were not under positive 

pressure. The facility had identified these deficiencies and 

had plans to relocate both the GU and radiology/ultrasound 

reprocessing to areas with proper ventilation. 

SOPs. VHA requires SOPs for all pieces of RME to be 

current and consistent with manufacturers’ guidelines.11 We 

reviewed the SOP for stainless steel dental instruments and 

found that it was not consistent with the manufacturer’s 

guidelines. Additionally, although the SOP for the 

colonoscope was current and consistent with the 

manufacturer’s guidelines, during our observation of the 

cleaning, we found that the employee did not follow the 

procedural steps indicated by the SOP. 

Flash Sterilization. VA requires full sterilization procedures 

to be used for all surgical instruments.12 Flash sterilization (a 

shorter sterilization process) is to be used during a surgical 

procedure only in case of emergency, such as a dropped 

sterilized instrument. We reviewed 6 months of OR flash 

9 VA Handbook 7176. 

10 VA Handbook 7176. 11 VHA Directive 2009-004, Use and Reprocessing of Reusable Medical Equipment (RME) in Veterans Health
 

Administration Facilities, February 9, 2009.
 12 VA Handbook 7176.
 

VA OIG Office of Healthcare Inspections 6 
CAP Review of the Philadelphia VA Medical Center, Philadelphia, PA 

Recommendations 

EOC 

sterilization log documentation and found that flash 

sterilization was used in non-emergent situations. The 

facility self-identified the increased use of flash sterilization 

and recently changed their process to address the issue. 

6. We recommended that decontamination areas be 

restricted to authorized personnel. 

7. We recommended that staff wear appropriate PPE in 

decontamination areas. 

8. We recommended that ventilation system, air filter, and 

air exchange inspections be completed in accordance with 

VA policy. 

9. We recommended that SOPs for all pieces of RME be 

consistent with the manufacturers’ guidelines and that staff 

follow the procedural steps in the SOPs. 

10. We recommended that flash sterilization be used in the 

OR only in case of emergency and that ongoing monitoring 

of flash sterilization be continued. 

The purpose of this review was to determine whether VHA 

facilities maintained a safe and clean health care 

environment. VHA facilities are required to establish a 

comprehensive EOC program that fully meets VHA, National 

Center for Patient Safety, OSHA, NFPA, and TJC’s 

standards. 

We inspected selected inpatient (medical/surgical, medical 

intensive care, MH, CLC) units, three outpatient (women’s 

health, specialty, and primary care) clinics, the emergency 

department, the hemodialysis unit, the outpatient pharmacy, 

and all construction sites in the clinical areas. The facility 

maintained a generally clean and safe environment. 

However, we identified the following conditions that needed 

improvement. 

Safety. Reduction of environmental factors that may 

contribute to suicide attempts and other self-injurious 

behaviors is a high priority in VA locked behavioral health 

units. In the bathrooms of three patient rooms on two 

different locked units, we found paper towel and trash 

cabinets with unlocked metal doors that could be used as 

anchor points. While we were onsite, the facility devised a 

VA OIG Office of Healthcare Inspections 7 
CAP Review of the Philadelphia VA Medical Center, Philadelphia, PA 

plan to address the hazard temporarily while pursuing 

options for a more permanent solution. 

VHA policy requires that eyewash stations and/or showers 

be provided for emergency use in work areas where 

exposure to corrosive materials, blood, potentially infectious 

materials, and specified chemicals may occur.13 All 

emergency eyewash stations must provide tepid water and 

be in unobstructed, accessible locations. Supervisors and 

employees must undergo appropriate training in the 

operation, use, and inspection of the eyewash station. We 

found one high-risk area that did not have an eyewash 

station, one eyewash station that staff were unable to 

demonstrate provided a safe water temperature, and one 

eyewash station that was not readily accessible to staff. 

Additionally, staff informed us that they had not received 

training in the use and operation of the eyewash stations that 

were present. 

Patients with certain infectious diseases are placed in 

negative pressure rooms to help control the spread of certain 

airborne pathogens. When the negative pressure room is 

occupied, the Centers for Disease Control and Prevention 

require daily testing and documentation of the room’s 

ventilation system. The facility did not have a process in 

place for the daily testing and documentation of negative 

pressure room ventilation systems. 

TJC requires that medications be stored appropriately, that 

stored medications be labeled with expiration dates, and that 

drugs be removed promptly upon expiration. On one unit, 

we found insulin vials stored inappropriately and one opened 

vial of insulin without an expiration date. On another unit, we 

found two expired vials of insulin stored in the medication 

refrigerator. 

Dialysis Unit. The ANSI and the AAMI require monthly 

biological testing of water and dialysate used for dialysis.14 

We reviewed 12 months of culture reports and found that 

staff documentation of biological testing was inconsistent. 

Training. IC guidelines and local policy require that certain 

categories of staff undergo annual OSHA Bloodborne 

Pathogen Rule training. We found that only 17 (74 percent) 

13 VHA Directive 2009-026; Location, Selection, Installation, Maintenance, and Testing of Emergency Eyewash and
 

Shower Equipment; May 13, 2009.
 14 Solution used to remove waste products from the blood during dialysis.
 

VA OIG Office of Healthcare Inspections 8 
CAP Review of the Philadelphia VA Medical Center, Philadelphia, PA 

of 23 applicable staff records reviewed showed evidence of 

bloodborne pathogens training. 

VHA policy requires that staff who work on locked inpatient 

MH units and members of the MSIT undergo initial and 

annual training on environmental hazards that represent a 

threat to suicidal patients.15 Documentation of annual MH 

environmental hazards training was incomplete for the five 

MH unit employees and five MSIT members whose records 

we reviewed. 

OSHA requires that staff identified to wear an N95 respirator 

undergo initial and annual fit testing and training. Only 

1 (5 percent) of the 20 records reviewed of staff who worked 

in areas at high risk for exposure to airborne pathogens 

contained documentation of current testing and training. 

CBOC Rounds. In the previous CAP report, we 

recommended that all designated EOC team members 

participate in all EOC rounds, that all CBOCs be inspected 

semi-annually, and that documentation of EOC rounds be 

complete. We found that CBOCs were inspected 

semi-annually and that documentation of EOC rounds was 

complete; however, documentation showed that on average, 

only 55 percent of team members or their designees 

participated in all EOC rounds. The EOC rounds attendance 

issue is a repeat finding. 

Recommendations	 11. We recommended that the facility develop a plan of 

action to address the environmental hazard on the locked 

MH units that represents a threat to suicidal patients. 

12. We recommended that a self-assessment be conducted 

to ensure that issues with storage and labeling of 

medications, eyewash stations, and negative pressure rooms 

are identified throughout the facility and that corrective 

actions be taken as necessary. 

13. We recommended that dialysis staff consistently 

document biological testing. 

14. We recommended that designated staff undergo annual 

OSHA Bloodborne Pathogen Rule training, locked MH unit 

environmental hazards training, and fit testing and training. 

15 Deputy Under Secretary for Health for Operations and Management, “Mental Health Environment of Care 

Checklist” memorandum, August 27, 2007. 

VA OIG Office of Healthcare Inspections 9 
CAP Review of the Philadelphia VA Medical Center, Philadelphia, PA 

15. We recommended that all EOC team members or their 

designees attend all EOC rounds and that attendance be 

documented. 

MRI Safety	 The purpose of this review was to evaluate whether the 

facility maintained a safe environment and safe practices in 

the MRI area. Safe MRI procedures minimize risk to 

patients, visitors, and staff and are essential to quality patient 

care. VA’s MRI safety policy is detailed in an online resource 

guide that establishes requirements for safe MRI practices.16 

We inspected the MRI area, examined patient and employee 

records, reviewed relevant policies, and interviewed key 

personnel. We determined that the facility had adequate 

safety policies and had appropriately conducted a risk 

assessment of the environment as required by TJC. 

We found appropriate signage. We noted that patients were 

directly observed during MRIs. Two-way communication 

was available between the patient and the MRI technologist, 

and patients had access to a call system while in the 

scanner. Additionally, mock fire and emergency response 

drills had been conducted in the MRI area. We identified the 

following areas that needed improvement. 

Safety Screening. VA and the American College of 

Radiology require screening of patients undergoing MRI. 

MRI technologists are required to review and sign the 

questionnaires and address any positive responses before a 

patient is scanned. A positive response on the 

questionnaire, such as an implanted device, must be 

addressed before a patient is scanned. We found complete 

documentation of technologist screenings in 7 (70 percent) of 

the 10 patient records that we reviewed. 

Local policy requires the referring physician to complete an 

initial screening of the patient at the time the procedure is 

ordered. We found referring physician screenings in 

only 1 (10 percent) of 10 patient records reviewed. The 

facility identified this prior to our visit and was developing a 

new order entry procedure to ensure documentation of initial 

screening by referring physicians. 

Safety Training. The American College of Radiology 

requires that MRI personnel and non-MRI personnel who 

16 VA Radiology, “Online Guide,” <http://vaww1.va.gov/Radiology/page.cfm?pg=167>, updated 

December 20, 2007, Secs. 4.1–4.3. 

VA OIG Office of Healthcare Inspections 10 
CAP Review of the Philadelphia VA Medical Center, Philadelphia, PA 

have access to the MRI area receive appropriate safety 

training. We reviewed the training records of six MRI 

personnel and six non-MRI personnel. All six MRI personnel 

had evidence of ongoing safety training. Two of the six 

non-MRI personnel did not have complete documentation of 

training. 

Recommendations	 16. We recommended that MRI personnel address any 

positive responses identified on the screening questionnaires 

and document actions taken and that referring physicians 

document initial MRI screenings. 

17. We recommended that non-MRI personnel who have 

access to the MRI area receive the appropriate level of MRI 

safety training and that the training be documented. 

Review Activities Without Recommendations 

COC	 The purpose of this review was to evaluate whether 

inter-facility transfers and discharges were coordinated 

appropriately over the continuum of care and met VHA and 

TJC’s requirements. Coordinated transfers and discharges 

are essential to an integrated, ongoing care process and 

optimal patient outcomes. 

VHA requires that facilities have a policy that ensures the 

safe, appropriate, and timely transfer of patients and that 

transfers are monitored and evaluated as part of the QM 

program.17 We determined that the facility had an 

appropriate transfer policy and that acceptable monitoring 

was in place. 

VHA requires specific information (such as the reason for 

transfer and services required) to be recorded in the transfer 

documentation. We reviewed documentation for 12 patients 

who transferred from the facility’s acute inpatient unit, 

emergency department, or urgent care clinic to another 

facility. We determined that clinicians consistently 

documented the required information for the patient transfers 

reviewed. 

VHA policy and TJC’s standards require that providers 

include information regarding medications, diet, activity level, 

and follow-up appointments in written patient discharge 

instructions.18 We reviewed the medical records of 

17 VHA Directive 2007-015, Inter-Facility Transfer Policy, May 7, 2007. 18 VHA Handbook 1907.01. 

VA OIG Office of Healthcare Inspections 11 
CAP Review of the Philadelphia VA Medical Center, Philadelphia, PA 

Medication 

Management 

Suicide Prevention 

Safety Plans 

18 discharged patients and determined that clinicians had 

generally documented the required elements. Also, we 

found that follow-up appointments occurred within the 

timeframes specified. We made no recommendations. 

The purpose of this review was to evaluate whether the 

facility had developed effective and safe medication 

management practices. We reviewed selected medication 

management processes for outpatients and CLC residents. 

The facility had implemented a practice guideline governing 

the maintenance of chronic renal disease patients who 

receive erythropoiesis-stimulating agents.19 We found that 

clinical staff had appropriately identified and addressed 

elevated hemoglobin levels in the 10 patients whose medical 

records we reviewed. In general, influenza vaccinations 

were documented adequately for CLC residents. Also, we 

found that the pharmacy operated 24 hours a day, 7 days a 

week and had qualified staff to answer questions. We made 

no recommendations. 

The purpose of this review was to determine whether 

clinicians had developed safety plans that provided 

strategies to mitigate or avert suicidal crises for patients 

assessed to be at high risk for suicide. Safety plans should 

have patient and/or family input, be behavior oriented, and 

identify warning signs preceding crisis and internal coping 

strategies. They should also identify when patients should 

seek non-professional support, such as from family and 

friends, and when patients need to seek professional help. 

Safety plans must also include information about how 

patients can access professional help 24 hours a day, 7 days 

a week.20 

A previous OIG review of suicide prevention programs in 

VHA facilities found a 74 percent compliance rate with safety 

plan development.21 The safety plan issues identified in that 

review were that plans were not comprehensive (did not 

contain the above elements), were not developed timely, or 

were not developed at all. At the request of VHA, the OIG 

agreed to follow up on the prior findings. 

19 Drugs that stimulate the bone marrow to make red blood cells; used to treat anemia.
 20 Deputy Under Secretary for Health for Operations and Management, “Patients at High-Risk for Suicide,”
 

memorandum, April 24, 2008.

21 Healthcare Inspection – Evaluation of Suicide Prevention Program Implementation in Veterans Health 

Administration Facilities January–June, 2009; Report No. 09-00326-223; September 22, 2009. 

VA OIG Office of Healthcare Inspections 12 
CAP Review of the Philadelphia VA Medical Center, Philadelphia, PA 

We reviewed the medical records of 10 patients assessed to 

be at high risk for suicide and found that clinicians had 

developed timely safety plans that included all required 

elements in 9 (90 percent) of the 10 records. The Suicide 

Prevention Coordinator recognized the need to consistently 

track safety plans and remind VA providers of the need for 

timely development of all safety plans. We also found 

evidence to support that the patients and/or their families 

participated in the development of the plans. 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 19–25, 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 13 
CAP Review of the Philadelphia VA Medical Center, Philadelphia, PA 

Appendix A 

Facility Profile22 

Type of Organization Tertiary care medical center 

Complexity Level 1b 

VISN 4 

CBOCs Horsham, PA 

Philadelphia, PA 

Gloucester, NJ 

Fort Dix, NJ 

Camden, NJ 

Veteran Population in Catchment Area 336,253 

Type and Number of Total Operating Beds: 

 Hospital, including Psychosocial 

Residential Rehabilitation Treatment 

Program 

142 

 CLC/Nursing Home Care Unit 135 

 Other 0 

Medical School Affiliation(s) University of Pennsylvania 

 Number of Residents 108 

Current FY (through 

May 2010) 

Prior FY (2009) 

Resources (in millions): 

 Total Medical Care Budget $409.6 $375.9 

 Medical Care Expenditures $409.6 $375.9 

Total Medical Care Full-Time Employee 

Equivalents 

1,972.5 1,918.9 

Workload: 

 Number of Station Level Unique 

Patients 

61,499 68,812 

 Inpatient Days of Care: 

o Acute Care 27,698 44,177 

o CLC/Nursing Home Care Unit 24,872 45,343 

Hospital Discharges 3,774 5,433 

Total Average Daily Census (including all bed 

types) 

231.3 245.3 

Cumulative Occupancy Rate 83.5% 88.5% 

Outpatient Visits 338,625 471,688 

22 All data provided by facility management. 

VA OIG Office of Healthcare Inspections 14 
CAP Review of the Philadelphia VA Medical Center, Philadelphia, PA 

Appendix B 

Follow-Up on Previous Recommendations 

Recommendations Current Status of Corrective Actions 

Taken 

In 

Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

QM 

1. Report data analyses to appropriate 

committees, and document, implement, and 

monitor corrective actions. 

Action plans are not consistently 

documented. 

N Y (see page 3) 

2. Document training of staff performing 

peer reviews, complete initial and final peer 

reviews in appropriate timeframes, and track 

and follow action items. 

Data is timely documented and presented 

quarterly to the Medical Executive 

Committee. 

Y N 

3. Require appropriate committees to track 

and trend patient complaint data. 

Patient complaint data is tracked and 

results trended by the Patient Advocate 

and reported to the Quality Council on a 

semi-annual basis. 

Y N 

4. Improve root cause analysis processing 

times. 

Root cause analysis timeliness is a 

performance measure for Patient Safety 

staff, and monthly status reports are 

presented to the facility’s Director. 

Y N 

5. Ensure staff complete handoff 

communication education. 

A handoff communications policy with an 

SBAR tool was developed, and staff were 

appropriately educated and trained in the 

use of the SBAR tool. 

Y N 

6. Improve review of admission and 

continued stay cases not meeting facility 

criteria. 

UM reports quarterly to the Quality 

Council. UM nurses have completed 

training in NUMI. The Fix Flow 

Committee, of which UM is an integral 

partner, meets weekly. Medicine UM 

reviewer attends daily medicine rounds. 

Y N 

VA OIG Office of Healthcare Inspections 15 
CAP Review of the Philadelphia VA Medical Center, Philadelphia, PA 

Recommendations Current Status of Corrective Actions 

Taken 

In 

Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

7. Require the Patient Flow Committee to 

meet regularly to implement and evaluate 

action plans. 

Patient Flow Committee has been 

revamped to include key facility leaders. 

Minutes of meetings include 

documentation of assigned actions. 

Y N 

EOC 

8. Require all EOC team members to 

participate in all rounds, rounds to be 

completed in CBOCs semi-annually, and 

documentation of all rounds to be complete. 

EOC rounds are documented and 

conducted semi-annually in all CBOCs 

Y, partially Y (see page 9) 

9. Ensure staff on 7E receive appropriate 

fire response and fire plan training and are 

issued fire extinguisher keys 

Staff received keys and completed 

training. 

Y N 

SHEP 

10. Develop and implement an action plan to 

improve patient care based on internal 

surveys and SHEP data results 

A SHEP Subcommittee reports monthly to 

the Customer Service Committee. 

Y N 

Computerized Patient Record System 

Business Rules 

11. Comply with VHA Handbook 1907.1 and 

the October 2004 OI guidance 

The facility removed noncompliant 

business rules while inspectors were 

onsite at the time of the previous CAP. 

Y N 

Surgical Care Improvement Project 

12. Develop Computerized Patient Record 

System templates for patients receiving 

post-anesthesia care. 

Staff in post-anesthesia recovery received 

training and currently use only electronic 

documentation. 

Y N 

VA OIG Office of Healthcare Inspections 16 
CAP Review of the Philadelphia VA Medical Center, Philadelphia, PA 

Appendix C 

VHA Satisfaction Surveys
 VHA has identified patient and employee satisfaction scores as significant indicators of 

facility performance. Patients are surveyed monthly. VHA is currently in the process of 

transitioning to the Consumer Assessment of Healthcare Providers and Systems 

survey. As a result, data for FY 2009 have been summarized for the entire year. 

Table 1 below shows facility, VISN, and VHA calibrated overall inpatient and outpatient 

satisfaction scores for FY 2009 and overall inpatient and outpatient satisfaction scores 

and targets for the 1st and 2nd quarters of FY 2010. 

Table 1 

FY 2009 FY 2010 

(inpatient target = 64; outpatient target = 56) 

Inpatient 

Score 

Outpatient 

Score 

Inpatient 

Score 

Quarter 1 

Inpatient 

Score 

Quarter 2 

Outpatient 

Score 

Quarter 1 

Outpatient 

Score 

Quarter 2 

Facility 57.87 46.92 51.2 48.4 43.0 54.6 

VISN 69.53 59.14 62.7 65.5 59.5 61.4 

VHA 65.01 52.87 63.3 63.9 54.7 55.2 

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 17 
CAP Review of the Philadelphia VA Medical Center, Philadelphia, PA 

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

conditions23 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 12.91 7.7 16.13 19.88 21.09 14.16 

VHA 13.31 9.73 15.08 20.57 21.71 15.85 

23 Congestive heart failure (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 sedition of 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 18 
CAP Review of the Philadelphia VA Medical Center, Philadelphia, PA 

Appendix D 

VISN Director Comments 

Department of 

Veterans Affairs Memorandum 

Date:	 Dec. 7, 2010 

From:	 Director, VA Stars and Stripes Healthcare Network (10N4) 

Subject:	 CAP Review of the Philadelphia VA Medical Center, 

Philadelphia, PA 

To:	 Director, Washington, DC, Healthcare Inspections Division 

(54DC) 

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

I have reviewed the response to the draft OIG CAP report provided by the 

Philadelphia VA Medical Center and concur with the response. I am 

submitting it to your office as requested. If you have any questions or 

require additional information, please contact Barbara Forsha, VISN QMO 

at 412-822-3290.

 (original signed by:) 

MICHAEL E. MORELAND, FACHE 

VA OIG Office of Healthcare Inspections 19 
CAP Review of the Philadelphia VA Medical Center, Philadelphia, PA 

Appendix E 

Facility Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: Dec. 1, 2010 

From: Director, Philadelphia VA Medical Center (642/00) 

Subject: CAP Review of the Philadelphia VA Medical Center, 

Philadelphia, PA 

To: Director, VA Stars and Stripes Healthcare Network (10N4) 

We concur with the recommendations stated in the OIG CAP inspection 

report. Attached is our implementation plan showing specific corrective 

actions and target completion dates.

 (original signed by:) 

Joseph M. Dalpiaz 

Medical Center Director 

VA OIG Office of Healthcare Inspections 20 
CAP Review of the Philadelphia VA Medical Center, Philadelphia, PA 

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 committee minutes identify action plans, 

assign responsibility, track open action items, and monitor implemented changes. 

Concur 

Target date for completion: January 31, 2011 

The facility has a template for minutes that includes tracking of open items. The 

minutes need to be more robust in content so the reader knows exactly what is 

occurring. An education plan to train both the Chairpersons and the recorders of 

committee minutes will be developed. Target date for completion of education plan is 

December 30, 2010. The facility will schedule a mandatory training class regarding the 

preparation of minutes to include improving content, identifying action plans, assigning 

responsibility, tracking open action items and monitoring implemented changes. 

Required attendance is Committee Chairpersons and minute scribes. Target date for 

completion of training is January 31, 2011. 

Recommendation 2. We recommended that PR extensions be requested in writing 

and approved by the facility’s Director. 

Concur 

Target date for completion: October 31, 2010 

The risk management team developed a tracking log to ensure that extensions are 

requested in a timely fashion. Facility is currently at 100 percent compliance. Facility 

will continue to monitor. This was completed on October 31, 2010. 

Recommendation 3. We recommended that reporting of patient complaint data 

comply with VHA policy. 

Concur: 

Target date for completion: October 31, 2010 

Patient complaint data has been changed to report quarterly to Quality Council. This 

data will be presented to executive leadership and other key staff who are members of 

Quality Council. Reporting calendar has been updated. Action completed 

October 31, 2010. 

VA OIG Office of Healthcare Inspections 21 
CAP Review of the Philadelphia VA Medical Center, Philadelphia, PA 

Recommendation 4. We recommended that the facility monitor the copy and paste
 

functions in the electronic medical record.
 

Concur:
 

Target date for completion: September 21, 2010
 

A policy is in place and approved by Medical Records Committee. A tool has been
 

developed for monitoring copying and pasting functions in the medical records and was
 

implemented on September 21, 2010. Data will continue to be reviewed and monitored
 

by the Medical Records Committee. Action completed on September 21, 2010.
 

Recommendation 5. We recommended that all physicians’ profiles include sufficient
 

OPPE data and that all privileges be setting specific.
 

Concur
 

Target date for completion: February 28, 2011
 

The facility has a process in place and is being used in the granting of provider
 

privileges. Recent education was provided to key clinical leaders on the collection of
 

OPPE data. The facility will implement a process to comply with VHA requirements for
 

physician privileging and will make two attempts to get privileges from other institutions
 

where the provider holds privileges.
 

Recommendation 6. We recommended that decontamination areas be restricted to
 

authorized personnel.
 

Concur
 

Target date for completion: December 31, 2010
 

The facility will restrict access to decontamination areas to authorized personnel only.
 

Recommendation 7. We recommended that staff wear appropriate PPE in
 

decontamination areas.
 

Concur 

Target date for completion: January 31, 2011 

The facility has a policy in place for PPE and staff has been educated on policy. 

Radiology and CT area completed re-education of staff on September 20, 2010. GU 

area to complete re-education on policy. 

VA OIG Office of Healthcare Inspections 22 
CAP Review of the Philadelphia VA Medical Center, Philadelphia, PA 

Recommendation 8. We recommended that ventilation system, air filter, and air 

exchange inspections be completed in accordance with VA policy. 

Concur 

Target date for completion: December 6, 2010 

The facility has completed the required quarterly ventilation and air flow inspections and

is in compliance with regulations. Initial inspection was completed on July 12, 2010.

Subsequent inspection date was September 13, 2010. The next scheduled inspection 

is December 6, 2010. Action completed on December 6, 2010. 

Recommendation 9. We recommended that SOPs for all pieces of RME be consistent 

with the manufacturers’ guidelines and that staff follow the procedural steps in the 

SOPs. 

Concur 

Target date for completion: January 31, 2011 

SOPs for RME have been developed and staff has been trained to follow the 

procedural steps in the SOPs. 

Recommendation 10. We recommended that flash sterilization be used in the OR only 

in case of emergency and that ongoing monitoring of flash sterilization be continued. 

Concur 

Target date for completion: December 31, 2011 

The facility will continue to monitor flash sterilization rate, analyze reasons for flash will 

be documented, and monthly reports provided to Infection Control Committee. 

Recommendation 11. We recommended that the facility develop a plan of action to 

address the environmental hazard on the locked MH units that represents a threat to 

suicidal patients. 

Concur 

Target date for completion: Closed 

The facility developed an immediate plan of action to address the environmental 

hazard on the locked MH units that represent a threat to suicidal patients. Monitoring 

is done daily and signed off by the EMS staff and Nursing Supervisor. The immediate 

plan of action put in place on September 17, 2010 is working well and has been 

implemented as a permanent process. Action completed on September 17, 2010. 

VA OIG Office of Healthcare Inspections 23 
CAP Review of the Philadelphia VA Medical Center, Philadelphia, PA 

Recommendation 12. We recommended that a self-assessment be conducted to 

ensure that issues with storage and labeling of medications, eyewash stations, and 

negative pressure rooms are identified throughout the facility and that corrective actions 

be taken as necessary. 

Concur 

Target date for completion: October 31, 2010 

The facility will conduct a self assessment to ensure issues with storage and labeling of

medications, eye wash stations, and negative pressure rooms are identified throughout

the facility and that corrective actions are taken. 

Recommendation 13. We recommended that dialysis staff consistently document 

biological testing. 

Concur 

Target date for completion: December 31, 2010 

Biologic Testing of water and dialysate will be properly performed in dialysis area and 

results reported on a routine basis to Infection Control Committee. 

Recommendation 14. We recommended that designated staff undergo annual OSHA 

Bloodborne Pathogen Rule training, locked MH unit environmental hazards training, and 

fit testing and training. 

Concur 

Target date for completion: April 30, 2011 

The facility will conduct training for designated staff on OSHA Blood Borne Pathogen 

Rule, locked MH environmental hazards and fit testing. 

Recommendation 15. We recommended that all EOC team members or their 

designees attend all EOC rounds and that attendance be documented. 

Concur 

Target date for completion: March 31, 2011 

Staff performing CBOC rounds will be educated to sign for all areas that they review. 

Attendance will be documented and monitored. 

VA OIG Office of Healthcare Inspections 24 
CAP Review of the Philadelphia VA Medical Center, Philadelphia, PA 

Recommendation 16. We recommended that MRI personnel address any positive 

responses identified on the screening questionnaires and document actions taken and 

that referring physicians document initial MRI screenings. 

Concur 

Target date for completion: February 28, 2011 

MRI personnel have been trained in MRI patient safety screening. Training completed 

on October 15, 2010. A template is under development for positive responses identified 

on screening questionnaires by referring physician to ensure documentation of initial 

MRI screenings. Template is to be completed by December 31, 2010. Target date for 

implementation of the template process is February 28, 2011. 

Recommendation 17. We recommended that non-MRI personnel who have access to 

the MRI area receive the appropriate level of MRI safety training and that the training be 

documented. 

Concur 

Target date for completion: March 31, 2011 

The facility will ensure that all MRI and non-MRI staff will receive appropriate level of 

MRI safety training and that the training is documented. 

VA OIG Office of Healthcare Inspections 25 
CAP Review of the Philadelphia VA Medical Center, Philadelphia, PA 

Appendix F 

OIG Contact and Staff Acknowledgments 

Contact	 Kathy Gudgell, Team Leader 

Washington, DC, Office of Healthcare Inspections 

Contributors	 Bruce Barnes 

Gail Bozzelli 

Donald Braman 

Jennifer Christensen 

Myra Conway 

Melanie Cool 

Katharine Foster 

Donna Giroux 

Frank Miller 

Kimberly Pugh 

Judith Thomas 

Natalie Sadow-Colón, Program Support Assistant 

Robert Breunig, Newark Office of Investigations 

Joseph Dattoria, Newark Office of Investigations 

Mark Lazarowitz, Newark Office of Investigations 

Report Produced under the direction of Randall Snow, J.D. 

Preparation Director, Washington, DC, Office of Healthcare Inspections 

VA OIG Office of Healthcare Inspections 26 
CAP Review of the Philadelphia VA Medical Center, Philadelphia, PA 

Appendix G 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VA Stars and Stripes Healthcare Network (10N4) 

Director, Philadelphia VA Medical Center (642/00) 

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: Robert P. Casey, Jr.; Pat Toomey 

U.S. House of Representatives: Robert Brady, Chaka Fattah, Michael Fitzpatrick, 

Jim Gerlach, Pat Meehan, Jon Runyan, Allyson Y. Schwartz 

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

VA OIG Office of Healthcare Inspections 27