Department of Veterans Affairs 

Office of Inspector General 

Office of Healthcare Inspections
 

Report No. 11-02077-282 

Combined Assessment Program
 

Review of the White River Junction
 

VA Medical Center
 

White River Junction, Vermont
 

September 15, 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 White River Junction VA Medical Center, White River Junction, VT 

Glossary 

C&P credentialing and privileging 

CAP Combined Assessment Program 

COC coordination of care 

EN enteral nutrition 

EOC environment of care 

facility White River Junction VA Medical Center 

FY fiscal year 

OIG Office of Inspector General 

QM quality management 

RN registered nurse 

VHA Veterans Health Administration 

VISN Veterans Integrated Service Network 

VA OIG Office of Healthcare Inspections 
CAP Review of the White River Junction VA Medical Center, White River Junction, VT 

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
 

COC .................................................................................................................. 3
 

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

EN Safety .......................................................................................................... 4
 

EOC................................................................................................................... 5
 

Review Activities Without Recommendations ......................................................... 5
 

Management of Workplace Violence................................................................. 5
 

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

QM..................................................................................................................... 6
 

RN Competencies ............................................................................................. 6
 

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

Appendixes 

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

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

C. VHA Satisfaction Surveys and Hospital Outcome of Care Measures................ 12
 

D. VISN Director Comments .................................................................................. 14
 

E. Facility Director Comments ............................................................................... 15
 

F. OIG Contact and Staff Acknowledgments ......................................................... 18
 

G. Report Distribution ............................................................................................ 19
 

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

Review of the White River Junction VA Medical Center,
 

White River Junction, VT
 

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 

July 11, 2011. 

Review Results: The review covered 

eight activities. We made no 

recommendations in the following 

activities: 

 Management of Workplace Violence 

 Medication Management 

 Quality Management 

 Registered Nurse Competencies 

The facility’s reported accomplishments 

were the development of a tracking 

system for reusable medical equipment, 

the hospice chorus, and the Veterans 

Free Farmers’ Market. 

Recommendations: We made 

recommendations in the following four 

activities: 

Coordination of Care: Ensure all 

components of written advance directive 

notification are provided to each patient, 

and document notification in the medical 

record. Update facility advance 

directive policy to identify the staff 

responsible for notification and to 

address the training requirements for 

staff involved in advance care planning 

discussions. 

Physician Credentialing and Privileging: 

Ensure all privileges granted are 

appropriate for the clinical settings. 

Enteral Nutrition Safety: Ensure that 

enteral nutrition documentation includes 

all required elements and that 

compliance is monitored. 

Environment of Care: Ensure that 

employees with occupational exposure 

risk receive annual bloodborne 

pathogens training and that compliance 

is monitored. 

Comments 

The Veterans Integrated Service 

Network and Facility Directors agreed 

with the Combined Assessment 

Program review findings and 

recommendations and provided 

acceptable improvement plans. We will 

follow up on the planned actions until 

they are completed. 

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

Assistant Inspector General for
 

Healthcare Inspections
 

VA OIG Office of Healthcare Inspections i 
CAP Review of the White River Junction VA Medical Center, White River Junction, VT 

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 eight activities: 

	 COC 

	 EN Safety 

	 EOC 

	 Management of Workplace Violence 

	 Medication Management 

	 Physician C&P 

	 QM 

	 RN Competencies 

The review covered facility operations for FY 2010 and 

FY 2011 through June 30, 2011, and was done in 

accordance with OIG standard operating procedures for CAP 

reviews. We also followed up on selected recommendations 

from our prior CAP review of the facility (Combined 

Assessment Program Review of the White River Junction VA 

VA OIG Office of Healthcare Inspections 1 
CAP Review of the White River Junction VA Medical Center, White River Junction, VT 

Medical Center, White River Junction, Vermont, Report 

No. 08-02559-50, December 30, 2008). The facility had 

corrected all findings. (See Appendix B for further details.) 

During this review, we also presented crime awareness 

briefings for 89 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
 Reusable Medical	 

Equipment 

Labeling Project 

The Sterile Processing Department Team designed and 

implemented a Supply Processing and Distribution 

management package to streamline surgical instrument 

sterilization, tracking, and identification. The program 

creates repositories of information, such as an inventory of 

all instruments and instructions for their assembly, cleaning, 

and maintenance. It also generates productivity reports and 

instrument maintenance schedules and is easily expanded 

since data fields can be added as needed. The facility now 

has a complete inventory of all items and a systematic 

labeling system for each item. 

Due to easy access to manufacturers’ instructions and 

standard operating procedures through the system, cleaning 

and reprocessing have also been standardized. A bar code 

scanner logs all items into and out of the autoclave so that 

processing is automated and accurate. Additionally, 

sterilizer parameters were entered into the program to 

provide audio and visual feedback if an item is loaded 

incorrectly. Finally, each user has a unique sign-on for 

traceability and accountability. 

Hospice Chorus	 The chaplain established the hospice chorus in 2009. The 

a cappella group tries to provide comfort, relaxation, and 

support to dying veterans and their families during the last 

stage of life. The 29-member chorus includes employees, 

veterans, and other volunteers who give their time to those in 

need. Their repertoire includes songs from many cultures 

and traditions, including songs that address the journey of 

death and those that honor the joy of living. The music itself 

VA OIG Office of Healthcare Inspections 2 
CAP Review of the White River Junction VA Medical Center, White River Junction, VT 

The Veterans Free 

Farmers’ Market 

communicates emotions and wordless images, connecting 

with the experiences and memories of those who hear it. 

The Veterans Free Farmers’ Market is held weekly and 

offers outpatients free access to whole grain bread products, 

fruits, and vegetables. Volunteers at local markets and 

bakeries donate their excess produce and bread products. 

During harvest season, local farmers also contribute to the 

market. Additionally, access to informational pamphlets, 

recipes, and cookbooks is provided. 

As the concept of the market grew and was adopted by other 

agencies, it became necessary to establish a non-profit 

organization within the community to oversee the program. 

During the past 5 years, more than 200 tons of wholesome 

food has been delivered to 60 drop off points throughout the 

region. The program received the 2011 Excellence in 

Government Award from the Federal Executive Association 

of Vermont. 

Results 

Review Activities With Recommendations 

COC	 The purpose of this review was to evaluate whether the 

facility managed advance care planning and advance 

directives in accordance with applicable requirements. 

We reviewed patients’ medical records for evidence of 

advance directive notification, advance directive screening, 

and documentation of advance care planning discussions. 

We also reviewed the facility’s policy to determine whether it 

was consistent with VHA policy. We identified the following 

areas that needed improvement. 

Advance Directive Notification. VHA requires that all patients 

receive written notification at each admission to a VHA 

facility regarding their right to accept or refuse medical 

treatment, to designate a Health Care Agent, and to 

document their treatment preferences in an advance 

directive.1 As part of notification, each patient must be 

informed that VA does not discriminate based on whether or 

not the patient has an advance directive. We reviewed the 

medical records of 20 patients and found that none of the 

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

VA OIG Office of Healthcare Inspections 3 
CAP Review of the White River Junction VA Medical Center, White River Junction, VT 

records contained evidence of all components of written 

notification. 

Facility Policy. VHA requires that the facility identify the staff 

responsible for providing notification.2 In addition, VHA 

requires that the facility address the training requirements for 

staff involved in advance care planning discussions with 

patients. The facility’s policy did not designate the staff 

responsible for notification or address training requirements. 

Recommendations	 1. We recommended that processes be strengthened to 

ensure that all components of written advance directive 

notification are provided to each patient and that notification 

is documented in the medical record. 

2. We recommended that facility policy be updated to 

identify the staff responsible for providing advance directive 

notification and to address the training requirements for staff 

involved in advance care planning discussions with patients. 

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 15 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. 

Setting-Specific Privileges. VHA requires that clinical 

privileges be setting specific.3 The privileges for 5 of the 

15 providers whose files and profiles we reviewed were not 

appropriate for the approved clinical settings. For example, 

providers were credentialed to perform partial mastectomies 

in a clinic or emergency department. 

Recommendation	 3. We recommended that all privileges granted be 

appropriate for the clinical settings. 

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

facility established safe and effective EN procedures and 

practices in accordance with applicable requirements. 

We reviewed policies and documents related to EN and 

patients’ medical records. We also inspected areas where 

2 VHA Handbook 1004.02.
 3 VHA Handbook 1100.19, Credentialing and Privileging, November 14, 2008.
 

VA OIG Office of Healthcare Inspections 4 
CAP Review of the White River Junction VA Medical Center, White River Junction, VT 

EN products were stored while conducting the EOC review, 

and we interviewed key employees. We identified the 

following area that needed improvement. 

EN Documentation. VHA requires that staff document 

specific EN information in patients’ medical records.4 We 

reviewed the medical records of 10 EN patients (5 inpatients 

and 5 outpatients) and found that records did consistently 

address required information. For example, three of the five 

inpatient records did not include sufficient documentation 

that staff checked gastric residuals. 

Recommendation	 4. We recommended that processes be strengthened to 

ensure that EN documentation includes all required elements 

and that compliance is monitored. 

EOC	 The purpose of this review was to determine whether the 

facility maintained a safe and clean health care environment 

in accordance with applicable requirements. 

We inspected the intensive care, the mental health, two 

medical/surgical, and the same day surgery/post-anesthesia 

care units. We also inspected the emergency department, 

the rehabilitation clinic, and the medical sub-specialty clinic. 

The facility maintained a generally clean and safe 

environment. However, we identified the following condition 

that needed improvement. 

Infection Control. The Occupational Safety and Health 

Administration requires that employees with occupational 

exposure risk receive annual training on the Bloodborne 

Pathogens Rule. We reviewed 25 employee training records 

and found that 14 employees did not have this training 

documented. 

Recommendation	 5. We recommended that employees with occupational 

exposure risk receive annual bloodborne pathogens training 

and that compliance is monitored. 

Review Activities Without Recommendations
 

Management of	 

Workplace 

Violence 

The purpose of this review was to determine whether the 

facility issued and complied with a comprehensive policy 

regarding violent incidents and provided required training. 

4 VHA Handbook 1109.05, Specialized Nutritional Support, May 10, 2007. 

VA OIG Office of Healthcare Inspections 5 
CAP Review of the White River Junction VA Medical Center, White River Junction, VT 

Medication 

Management 

QM 

RN Competencies 

We reviewed the facility’s policy and training plan. 

Additionally, we selected three assaults that occurred at the 

facility within the past 2 years, discussed them with 

managers, and reviewed applicable documents. The facility 

had a comprehensive workplace violence policy and 

managed the assaults in accordance with policy. The 

training plan addressed the required prevention and 

management of disruptive behavior training. 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 same day surgery suite, 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 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. 

We made no recommendations. 

The purpose of this review was to determine whether the 

facility had an adequate RN competency assessment and 

validation process. 

We reviewed facility policies, interviewed nurse managers, 

and reviewed initial and ongoing competency assessments 

and validation documents for RNs. We determined that the 

facility had established an effective process to ensure that 

RN competencies were assessed and validated and that 

actions were taken when deficiencies were identified. We 

made no recommendations. 

VA OIG Office of Healthcare Inspections 6 
CAP Review of the White River Junction VA Medical Center, White River Junction, VT 

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 14–17, for the full text of the Directors’ comments.) We will follow up on 

the planned actions until they are completed. 

VA OIG Office of Healthcare Inspections 7 
CAP Review of the White River Junction VA Medical Center, White River Junction, VT 

Appendix A 

Facility Profile5 

Type of Organization General medical/surgical and psychiatric 

acute care facility 

Complexity Level 2 

VISN 1 

Community Based Outpatient Clinics Colchester, VT 

Rutland,VT 

Bennington, VT 

Brattleboro, VT 

Newport, NH 

Littleton, NH 

Veteran Population in Catchment Area 103,000 

Type and Number of Total Operating Beds: 

 Hospital, including Psychosocial 

Residential Rehabilitation Treatment 

Program 

60 acute care hospital beds 

Medical School Affiliation(s) Dartmouth Medical School, Hanover, NH 

The University of Vermont, Burlington, VT 

 Number of Residents 237 – current academic year 

Resources (in millions): 

 Total Medical Care Budget 

Current FY (through 

March 2011) 

$143.0 

Prior FY (2010) 

$153.2 

 Medical Care Expenditures $74.3 $153.2 

Total Medical Care Full-Time Employee 

Equivalents 

Workload: 

 Number of Station Level Unique 

Patients 

 Inpatient Days of Care: 

o Acute Care 

834.86 

19,496 

3,653 

802.11 

23,585 

14,090 

Hospital Discharges 1,195 2,338 

Total Average Daily Census (including all bed 

types) 

42.0 38.6 

Cumulative Occupancy Rate (in percent) 66.6 64.3 

Outpatient Visits 118,080 217,000 

5 All data provided by facility management. 

VA OIG Office of Healthcare Inspections 8 
CAP Review of the White River Junction VA Medical Center, White River Junction, VT 

Appendix B 

Follow-Up on Previous Recommendations 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

QM 

1. Collect, analyze, and use provider 

performance data during reprivileging. 

The Professional Standards Board 

developed a process for establishing 

service- and specialty-specific Focused 

and Ongoing Professional Practice 

Evaluation documentation. Minutes of 

the Clinical Executive Board reflect the 

use of this data during reprivileging. 

Y N 

2. Grant privileges that are consistent with 

providers’ practices. 

More specific privileging systems were 

approved and are currently in use by 

the Professional Standards Board. 

Y N 

3. Ensure that Peer Review Committee 

minutes reflect that recommended action 

items are implemented and that the 

committee reports quarterly to the Clinical 

Executive Board. 

Beginning with quarter 1 of FY 2009, a 

quarterly report of Peer Review 

Committee activity has been submitted 

to Clinical Executive Board. 

Y N 

4. Ensure that clinical managers monitor 

corrective actions and implement a plan to 

monitor anticoagulation therapy. 

A plan to monitor corrective actions of 

all open root cause analyses is in 

place, and the new tool is being used. 

Completion of action items will be 

evaluated and documented monthly. 

The anticoagulation directive has been 

updated to reflect VHA standards and 

has been implemented. Adverse drug 

events and medication errors are 

reported through the patient safety 

incident reporting system. 

Y N 

VA OIG Office of Healthcare Inspections 9 
CAP Review of the White River Junction VA Medical Center, White River Junction, VT 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

5. Ensure that clinicians discuss adverse 

events with patients and document the 

discussions in the medical records. 

Ongoing education was implemented 

for clinicians on adverse event 

documentation. Facility-wide training 

was completed December 31, 2008. 

The Risk Manager monitors and tracks 

disclosure documentation. 

Y N 

Medication Management 

6. Document pain reassessments within 

appropriate timeframes. 

Documentation of the effectiveness 

and timeliness of as needed pain 

medication is monitored at the unit and 

service level weekly. Nurse managers 

identify outliers and re-educate staff in 

documentation requirements. 

Y N 

7. Ensure that nurses scan all patients’ 

wristbands prior to medication 

administration. 

The results of 5 months of observation 

of staff who administer medications 

indicate 100 percent compliance with 

the Bar Code Medication 

Administration Policy, including 

scanning of patient wristbands. 

Y N 

Emergency/Urgent Care Clinic 

8. Ensure that emergency department RNs 

demonstrate required competencies annually 

and that compliance is documented. 

Completion of the competency 

checklist was added to Nursing’s 

Proficiency Tracking database; 

compliance is monitored by the 

Associate Director of Nursing for 

Patient Care Services. Episodes of 

non-compliance are reported to the 

Associate Nurse Executive. 

Y N 

VA OIG Office of Healthcare Inspections 10 
CAP Review of the White River Junction VA Medical Center, White River Junction, VT 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

COC 

9. Ensure that discharge instructions are 

consistent with discharge summaries and 

that patients receive written discharge 

instructions. 

Each clinical service has addressed 

the issue of consistency by reinforcing 

this requirement with attending 

physicians and house staff. The Chief 

of Staff’s office developed an initial 

observational process to assess 

consistency between discharge 

instructions and discharge summaries, 

which is to be done quarterly. Patients 

receive a copy of the discharge 

instructions with telephone follow-up. 

Y N 

Pharmacy Operations 

10. Maintain appropriate medication storage 

temperatures, and minimize security and 

infection control risks in the inpatient 

pharmacy. 

Facilities Management Service 

removed the air conditioner unit and 

cleaned the air ducts. Medication 

storage temperatures are monitored 

during environmental rounds. 

Y N 

VA OIG Office of Healthcare Inspections 11 
CAP Review of the White River Junction VA Medical Center, White River Junction, VT 

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 3 and 4 of FY 2010 and quarters 1 and 2 of FY 2011. 

Table 1 

FY 2010 FY 2011 

Inpatient Score 

Quarters 3 and 4 

Combined 

Outpatient 

Score 

Quarter 3 

Outpatient 

Score 

Quarter 4 

Inpatient Score 

Quarters 1 and 2 

Combined 

Outpatient 

Score 

Quarter 1 

Outpatient 

Score 

Quarter 2 

Facility 73.0 58.3 60.6 64.5 69.2 68.2 

VISN 63.5 62.7 61.6 65.2 62.3 60.6 

VHA 64.1 54.8 54.4 63.9 55.9 55.3 

Employees are surveyed annually. Figure 1 below shows the facility’s overall employee 

scores for 2009, 2010, and 2011. Since no target scores have been designated for 

employee satisfaction, VISN and national scores are included for comparison. 

VA OIG Office of Healthcare Inspections 12 
CAP Review of the White River Junction VA Medical Center, White River Junction, VT 

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 Congestive 

Heart 

Failure 

Pneumonia Heart Attack Congestive 

Heart 

Failure 

Pneumonia 

Facility 12.71 10.02 14.52 21.05 19.48 16.14 

VHA 13.31 9.73 15.08 20.57 21.71 15.85 

6 Congestive heart failure 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 13 
CAP Review of the White River Junction VA Medical Center, White River Junction, VT 

Appendix D 

VISN Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: August 12, 2011 

From: Director, VA New England Healthcare System (10N1) 

Subject: CAP Review of the White River Junction VA Medical 

Center, White River Junction, VT 

To: Director, Bedford Office of Healthcare Inspections (54BN) 

Director, Management Review Service (VHA 10A4A4 

Management Review) 

1. Attached is the reply to the CAP Review of the White River Junction 

VA Medical Center, White River Junction, VT issued August 5, 2011. 

2. If you have any questions regarding the information or require 

additional information, please contact Denise Lord at (781) 687-4850. 

(original signed by Henry Stankiewicz for:) 

Michael Mayo-Smith, MD 

Network Director VISN 1 

VA OIG Office of Healthcare Inspections 14 
CAP Review of the White River Junction VA Medical Center, White River Junction, VT 

Appendix E 

Facility Director Comments 

Department of 

Veterans Affairs	 Memorandum 

Date:	 August 24, 2011 

From:	 Director, White River Junction VA Medical Center (405/00) 

Subject:	 CAP Review of the White River Junction VA Medical 

Center, White River Junction, VT 

To:	 Director, VA New England Healthcare System (10N1) 

1. We concur with the findings and recommendations presented in the VA 

White River Junction OIG report of August 2011. Facility comments 

included in this final report comprise a brief implementation plan and 

target dates for each recommendation. 

2. We appreciated and benefited from the thorough review of the 

operation systems and processes, as well as from the consultative and 

helpful nature of the team members’ interactions with staff at all levels of 

our organization. The goal to provide excellent quality of care and 

services remains our primary mission; this OIG survey validated our 

quality of care and now provides additional opportunities for process 

improvement. 

3. Please contact me with additional questions or concerns regarding this 

report. 

Thank you, 

Robert M. Walton 

VA OIG Office of Healthcare Inspections 15 
CAP Review of the White River Junction VA Medical Center, White River Junction, VT 

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 processes be strengthened to ensure that 

all components of written advance directive notification are provided to each patient and 

that notification is documented in the medical record. 

Concur – The membership of the facility Integrated Ethics Committee has been 

enhanced and now includes staff closest to the process of Advance Care Planning as 

outlined in VHA Handbook 1004.02, Advance Care Planning and Management of 

Advance Directives (Published July 2009). Members are in the process of redesigning 

the facility policy and ensuring it includes all necessary elements. The final policy will 

specifically focus on individual staff responsibility for Advance Directives at the 

discipline level, will now include a process map/algorithm, and required medical record 

documentation triggers. A key element in our deployment of the new policy will be staff 

education. In addition, we will be revising the in and outpatient handbooks to include 

patient education, what to expect from our facility Advance Directive process, and 

information regarding who to contact when there are questions or concerns. 

Target date for completion: October 1, 2011 

Recommendation 2. We recommended that facility policy be updated to identify the 

staff responsible for providing advance directive notification and to address the training 

requirements for staff involved in advance care planning discussions with patients. 

Concur – In addition to the action plan noted above which includes policy redesign with 

a process map/algorithm for easy identification of staff specific responsibilities, a 

rigorous training activity(s) will be a key element of deployment. The training activity will 

be complete by December 1, 2011. 

Target date for completion: December 1, 2011 

Recommendation 3. We recommended that all privileges granted be appropriate for 

the clinical settings. 

Concur – Action for this recommendation includes the redesign of the facility level 

privilege request and approval template. As part of the VA national credentialing and 

privileging files scanning initiative, each provider’s file will be updated to include the 

revised template. Revisions to these providers’ files will reflect an administrative action 

as current privileges are accurate and appropriate. 

Target date for completion: December 31, 2011 

VA OIG Office of Healthcare Inspections 16 
CAP Review of the White River Junction VA Medical Center, White River Junction, VT 

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

EN documentation includes all required elements and that compliance is monitored. 

Concur – A multidisciplinary team made up of all staff who participate in the process of 

enteral nutrition has been formed and charged with redesigning the facility policy to 

include all elements of VA guidelines and facility specific monitoring. Quarterly 

monitoring of specific quality indicators will be conducted and presented to the 

Executive Committee of the Medical Staff beginning 2nd Qtr FY12. Reporting will be 

quarterly until such time as the medical staff deems less frequent reporting is 

appropriate. 

Target date for completion: October 1, 2011 

Recommendation 5. We recommended that employees with occupational exposure 

risk receive annual bloodborne pathogens training and that compliance is monitored. 

Concur – As of August 15, 98% of all employees having completed this training have 

their training documented appropriately. The remaining training will be completed and 

evidence of training appropriately documented by the action target date noted here. In 

addition, all blood borne pathogen training records are now entered into the employee 

TMS learning system. 

Target date for completion: October 1, 2011 

VA OIG Office of Healthcare Inspections 17 
CAP Review of the White River Junction VA Medical Center, White River Junction, VT 

Appendix F 

OIG Contact and Staff Acknowledgments 

Contact	 For more information about this report, please contact the 

Office of Inspector General at (202) 461-4720. 

Contributors	 Claire McDonald, MPA, Project Leader 

Lynn Sweeney, MD, Team Leader 

Annette Acosta, MN, RN 

Frank Keslof, EMT, MHA 

Glen Pickens, RN, MHSM 

Clarissa Reynolds, MBA 

William Nelson, Office of Investigations 

VA OIG Office of Healthcare Inspections 18 
CAP Review of the White River Junction VA Medical Center, White River Junction, VT 

Appendix G 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VA New England Healthcare System (10N1) 

Director, White River Junction VA Medical Center (405/00) 

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: Patrick J. Leahy, Bernard Sanders 

U.S. House of Representatives: Peter Welch 

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

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