Department of Veterans Affairs

Office of Inspector General 

Office of Healthcare Inspections 

Report No. 14-02068-264 

Combined Assessment Program 

Review of the 

Grand Junction VA Medical Center 

Grand Junction, Colorado 

September 2, 2014 

Washington, DC 20420 
To Report Suspected Wrongdoing in VA Programs and Operations 

Telephone: 1-800-488-8244 

E-Mail: vaoighotline@va.gov 

(Hotline Information: www.va.gov/oig/hotline) 
CAP Review of the Grand Junction VA Medical Center, Grand Junction, CO 

Glossary 

AIS acute ischemic stroke 

CAP Combined Assessment Program 

CLC community living center 

CRC colorectal cancer 

ED emergency department 

EHR electronic health record 

EOC environment of care 

facility Grand Junction VA Medical Center 

FY fiscal year 

MEC Medical Executive Committee 

MH mental health 

MRI magnetic resonance imaging 

NA not applicable 

NM not met 

OIG Office of Inspector General 

PACU post-anesthesia care unit 

PRC Peer Review Committee 

QM quality management 

SDS same day surgery 

tPA tissue plasminogen activator 

VHA Veterans Health Administration 

VISN Veterans Integrated Service Network 

VA OIG Office of Healthcare Inspections 
CAP Review of the Grand Junction VA Medical Center, Grand Junction, CO 

Table of Contents 

Page 

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

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

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

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

Results and Recommendations................................................................................ 3
 

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

EOC ........................................................................................................................ 6
 

Medication Management......................................................................................... 8
 

Coordination of Care ............................................................................................... 9
 

AIS Care ................................................................................................................. 10
 

CLC Resident Independence and Dignity ............................................................... 12
 

MRI Safety .............................................................................................................. 14
 

Review Activity with Previous CAP Recommendations ......................................... 16
 

Follow-Up on CRC Screening................................................................................. 16
 

Appendixes 

A. Facility Profile .................................................................................................... 17
 

B. Strategic Analytics for Improvement and Learning ............................................ 18
 

C. Acting VISN Director Comments ....................................................................... 21
 

D. Facility Director Comments ............................................................................... 22
 

E. OIG Contact and Staff Acknowledgments ......................................................... 29
 

F. Report Distribution ............................................................................................. 30
 

G. Endnotes ........................................................................................................... 31
 

VA OIG Office of Healthcare Inspections 
CAP Review of the Grand Junction VA Medical Center, Grand Junction, CO 

Executive Summary 

Review Purpose: The purpose of the review was to evaluate selected health care 

facility operations, focusing on patient care quality and the environment of care, and to 

provide crime awareness briefings. We conducted the review the week of July 7, 2014. 

Review Results: The review covered seven activities and one follow-up review area 

from the previous Combined Assessment Program review. We made no 

recommendations in the following two activities: 

 Medication Management 

 Coordination of Care 

Recommendations: We made recommendations in the following five activities and 

follow-up area: 

Quality Management: Ensure the Medical Executive Committee discusses and 

documents its approval of the use of another facility’s providers for teledermatology 

services. Consistently perform continuing stay reviews on at least 75 percent of 

patients in acute beds. Review the quality of entries in the electronic health record. 

Ensure the Blood Usage Review Committee member from Anesthesia Service 

consistently attends meetings. 

Environment of Care: Install nurse call system alarms in the emergency department. 

Date multi-dose medication vials when opened, and promptly remove expired 

medications from patient care areas. 

Acute Ischemic Stroke Care: Develop an acute ischemic stroke policy that addresses 

all required items, and fully implement the policy. Complete and document National 

Institutes of Health stroke scales for each stroke patient. Post stroke guidelines in the 

emergency department, on the critical care unit, and on all inpatient units. Screen 

patients for difficulty swallowing prior to oral intake, and provide printed stroke education 

to patients upon discharge. Collect and report to the Veterans Health Administration the 

percent of eligible patients given tissue plasminogen activator, the percent of patients 

with stroke symptoms who had the stroke scale completed, and the percent of patients 

screened for difficulty swallowing before oral intake. 

Community Living Center Resident Independence and Dignity: Ensure the Restorative 

Care Coordinator documents patient restorative program goals and progress weekly in 

accordance with facility policy. 

Magnetic Resonance Imaging Safety: Complete initial patient safety screenings, and 

document them in patients’ electronic health records. Complete secondary patient 

safety screenings immediately prior to magnetic resonance imaging, and place them in 

patients’ electronic health records. Identify any contraindications, and document 

VA OIG Office of Healthcare Inspections i 
CAP Review of the Grand Junction VA Medical Center, Grand Junction, CO 

resolution prior to magnetic resonance imaging. Ensure Level 2 personnel conducting 

secondary screenings sign the forms prior to the scan. 

Follow-Up on Colorectal Cancer Screening: Implement processes to monitor 

compliance with colorectal cancer timeliness and patient notification requirements. 

Comments 

The Acting Veterans Integrated Service Network Director and Facility Director agreed 

with the Combined Assessment Program review findings and recommendations and 

provided acceptable improvement plans. (See Appendixes C and D, pages 21–28, for 

the full text of the Directors’ comments.) 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 ii 
CAP Review of the Grand Junction VA Medical Center, Grand Junction, CO 

Objectives and 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 quality and the EOC. 

	 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 

The scope of the CAP review is limited. Serious issues that come to our attention that 

are outside the scope will be considered for further review separate from the CAP 

process and may be referred accordingly. 

For this review, we examined selected clinical and administrative activities to determine 

whether facility performance met requirements related to patient care quality and the 

EOC. In performing the review, we inspected selected areas, conversed with managers 

and employees, and reviewed clinical and administrative records. The review covered 

the following seven activities and follow-up review area from the previous CAP review: 

 QM 

 EOC 

 Medication Management 

	 Coordination of Care 

 AIS Care 

	 CLC Resident Independence and Dignity 

 MRI Safety 

	 Follow-Up on CRC Screening 

We have listed the general information reviewed for each of these activities. Some of 

the items listed may not have been applicable to this facility because of a difference 

in size, function, or frequency of occurrence. 

VA OIG Office of Healthcare Inspections 1 
 

CAP Review of the Grand Junction VA Medical Center, Grand Junction, CO 

The review covered facility operations for FY 2012, FY 2013, and FY 2014 through 

July 7, 2014, and was done in accordance with OIG standard operating procedures for 

CAP reviews. We also asked the facility to provide the status on the recommendations 

we made in our previous CAP report (Combined Assessment Program Review of the 

Grand Junction VA Medical Center, Grand Junction, Colorado, Report No. 11-03657-62, 

January 12, 2012). We made a recommendation in CRC Screening. 

During this review, we presented crime awareness briefings for 90 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. 

Additionally, we surveyed employees regarding patient safety and quality of care at the 

facility. An electronic survey was made available to all facility employees, and 

228 responded. We shared summarized results with facility managers. 

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. 

VA OIG Office of Healthcare Inspections 2 
CAP Review of the Grand Junction VA Medical Center, Grand Junction, CO 

Results and Recommendations 

QM 

The purpose of this review was to determine whether facility senior managers actively supported 

and appropriately responded to QM efforts and whether the facility met selected requirements 

within its QM program.a 

We conversed with senior managers and key QM employees, and we evaluated meeting 

minutes, EHRs, and other relevant documents. The table below shows the areas reviewed for 

this topic. The areas marked as NM did not meet applicable requirements and needed 

improvement. Any items that did not apply to this facility are marked NA. 

NM Areas Reviewed Findings 

There was a senior-level committee/group 

responsible for QM/performance improvement 

that met regularly. 

 There was evidence that outlier data was 

acted upon. 

 There was evidence that QM, patient 

safety, and systems redesign were 

integrated. 

The protected peer review process met 

selected requirements: 

 The PRC was chaired by the Chief of Staff 

and included membership by applicable 

service chiefs. 

 Actions from individual peer reviews were 

completed and reported to the PRC. 

 The PRC submitted quarterly summary 

reports to the MEC. 

 Unusual findings or patterns were 

discussed at the MEC. 

Focused Professional Practice Evaluations for 

newly hired licensed independent practitioners 

were initiated and completed, and results 

were reported to the MEC. 

X Specific telemedicine services met selected 

requirements: 

 Services were properly approved. 

 Services were provided and/or received by 

appropriately privileged staff. 

 Professional practice evaluation information 

was available for review. 

Twelve months of MEC meeting minutes 

reviewed: 

 There was no evidence that the MEC had 

approved the use of telemedicine technology 

for teledermatology services. 

VA OIG Office of Healthcare Inspections 3 
CAP Review of the Grand Junction VA Medical Center, Grand Junction, CO 

NM Areas Reviewed (continued) Findings 

Observation bed use met selected 

requirements: 

 Local policy included necessary elements. 

 Data regarding appropriateness of 

observation bed usage was gathered. 

 If conversions to acute admissions were 

consistently 30 percent or more, 

observation criteria and utilization were 

reassessed timely. 

X Staff performed continuing stay reviews on at 

least 75 percent of patients in acute beds. 

Twelve months of continuing stay data reviewed: 

 For 9 months, less than 75 percent of acute 

inpatients were reviewed. 

The process to review resuscitation events 

met selected requirements: 

 An interdisciplinary committee was 

responsible for reviewing episodes of care 

where resuscitation was attempted. 

 Resuscitation event reviews included 

screening for clinical issues prior to events 

that may have contributed to the 

occurrence of the code. 

 Data were collected that measured 

performance in responding to events. 

The surgical review process met selected 

requirements: 

 An interdisciplinary committee with 

appropriate leadership and clinical 

membership met monthly to review surgical 

processes and outcomes. 

 Surgical deaths with identified problems or 

opportunities for improvement were 

reviewed. 

 Additional data elements were routinely 

reviewed. 

Critical incidents reporting processes were 

appropriate. 

X The process to review the quality of entries in 

the EHR met selected requirements: 

 A committee was responsible to review 

EHR quality. 

 Data were collected and analyzed at least 

quarterly. 

 Reviews included data from most services 

and program areas. 

 There was no evidence that the quality of 

entries in the EHR was reviewed. 

The policy for scanning non-VA care 

documents met selected requirements. 

VA OIG Office of Healthcare Inspections 4 
CAP Review of the Grand Junction VA Medical Center, Grand Junction, CO 

NM Areas Reviewed (continued) Findings 

X The process to review blood/transfusions 

usage met selected requirements: 

 A committee with appropriate clinical 

membership met at least quarterly to review 

blood/transfusions usage. 

 Additional data elements were routinely 

reviewed. 

Twelve months of Blood Usage Review 

Committee meeting minutes reviewed: 

 The clinical representative from Anesthesia 

Service attended only two of four meetings. 

Overall, if significant issues were identified, 

actions were taken and evaluated for 

effectiveness. 

Overall, senior managers were involved in 

performance improvement over the past 

12 months. 

Overall, the facility had a comprehensive, 

effective QM/performance improvement 

program over the past 12 months. 

The facility met any additional elements 

required by VHA or local policy. 

Recommendations 

1. We recommended that the Medical Executive Committee discuss and document its 

approval of the use of another facility’s providers for teledermatology services. 

2. We recommended that processes be strengthened to ensure that continuing stay reviews 

are consistently performed on at least 75 percent of patients in acute beds. 

3. We recommended that processes be strengthened to ensure that the quality of entries in 

the electronic health record is reviewed. 

4. We recommended that processes be strengthened to ensure that the Blood Usage Review 

Committee member from Anesthesia Service consistently attends meetings. 

VA OIG Office of Healthcare Inspections 5 
  

 

CAP Review of the Grand Junction VA Medical Center, Grand Junction, CO 

EOC 

The purpose of this review was to determine whether the facility maintained a clean and safe 

health care environment in accordance with applicable requirements and whether the facility 

met selected requirements in SDS, the PACU, and the eye clinic.b 

We inspected the intensive care unit, two medical/surgical units, the MH unit, the ED, the CLC, 

SDS, the operating room, and the PACU. Additionally, we reviewed relevant documents, 

conversed with key employees and managers, and reviewed 19 employee training records 

(4 SDS, 10 operating room, and 5 PACU). The table below shows the areas reviewed for this 

topic. The areas marked as NM did not meet applicable requirements and needed 

improvement. Any items that did not apply to this facility are marked NA. 

NM Areas Reviewed for General EOC Findings 

EOC Committee minutes reflected sufficient 

detail regarding identified deficiencies, 

corrective actions taken, and tracking of 

corrective actions to closure. 

An infection prevention risk assessment was 

conducted, and actions were implemented to 

address high-risk areas. 

Infection Prevention/Control Committee 

minutes documented discussion of identified 

problem areas and follow-up on implemented 

actions and included analysis of surveillance 

activities and data. 

Fire safety requirements were met. 

X Environmental safety requirements were met.  We did not find nurse call systems in one of 

six patient care areas. 

Infection prevention requirements were met. 

X Medication safety and security requirements 

were met. 

 We found open, expired multi-dose 

medication vials in two of six patient care 

areas. 

Auditory privacy requirements were met. 

The facility complied with any additional 

elements required by VHA, local policy, or 

other regulatory standards. 

Areas Reviewed for SDS and the PACU 

Designated SDS and PACU employees 

received bloodborne pathogens training 

during the past 12 months. 

Designated SDS employees received medical 

laser safety training with the frequency 

required by local policy. 

Fire safety requirements in SDS and on the 

PACU were met. 

Environmental safety requirements in SDS 

and on the PACU were met. 

VA OIG Office of Healthcare Inspections 6 
CAP Review of the Grand Junction VA Medical Center, Grand Junction, CO 

NM Areas Reviewed for SDS and the PACU 

(continued) 

Findings 

SDS medical laser safety requirements were 

met. 

Infection prevention requirements in SDS and 

on the PACU were met. 

X Medication safety and security requirements 

in SDS and on the PACU were met. 

 We found an open, unlabeled multi-dose 

medication vial in one of two patient care 

areas. 

Auditory privacy requirements in SDS and on 

the PACU were met. 

The facility complied with any additional 

elements required by VHA, local policy, or 

other regulatory standards. 

Areas Reviewed for Eye Clinic 

NA Designated eye clinic employees received 

laser safety training with the frequency 

required by local policy. 

NA Environmental safety requirements in the eye 

clinic were met. 

NA Infection prevention requirements in the eye 

clinic were met. 

NA Medication safety and security requirements 

in the eye clinic were met. 

NA Laser safety requirements in the eye clinic 

were met. 

NA The facility complied with any additional 

elements required by VHA, local policy, or 

other regulatory standards. 

Recommendations 

5. We recommended that nurse call systems be installed in the emergency department. 

6. We recommended that processes be strengthened to ensure that multi-dose medication 

vials are dated when opened and expired medications are promptly removed from patient care 

areas and that compliance be monitored. 

VA OIG Office of Healthcare Inspections 7 
 

CAP Review of the Grand Junction VA Medical Center, Grand Junction, CO 

Medication Management 

The purpose of this review was to determine whether the appropriate clinical oversight and 

education were provided to patients discharged with orders for fluoroquinolone oral antibiotics.c 

We reviewed relevant documents and conversed with key managers and employees. 

Additionally, we reviewed the EHRs of 32 randomly selected inpatients discharged 

on 1 of 3 selected oral antibiotics. The table below shows the areas reviewed for this topic. 

Any items that did not apply to this facility are marked NA. The facility generally met 

requirements. We made no recommendations. 

NM Areas Reviewed Findings 

Clinicians conducted inpatient learning 

assessments within 24 hours of admission or 

earlier if required by local policy. 

If learning barriers were identified as part of 

the learning assessment, medication 

counseling was adjusted to accommodate the 

barrier(s). 

Patient renal function was considered in 

fluoroquinolone dosage and frequency. 

Providers completed discharge progress 

notes or discharge instructions, written 

instructions were provided to 

patients/caregivers, and EHR documentation 

reflected that the instructions were 

understood. 

Patients/caregivers were provided a written 

medication list at discharge, and the 

information was consistent with the dosage 

and frequency ordered. 

Patients/caregivers were offered medication 

counseling, and this was documented in 

patient EHRs. 

The facility established a process for 

patients/caregivers regarding whom to notify 

in the event of an adverse medication event. 

The facility complied with any additional 

elements required by VHA or local policy. 

VA OIG Office of Healthcare Inspections 8 
 

CAP Review of the Grand Junction VA Medical Center, Grand Junction, CO 

Coordination of Care 

The purpose of this review was to evaluate discharge planning for patients with selected 

aftercare needs.d 

We reviewed relevant documents and conversed with key employees. Additionally, 

we reviewed the EHRs of two patients with specific diagnoses who were discharged from 

July 1, 2012, through June 30, 2013. The table below shows the areas reviewed for this topic. 

Any items that did not apply to this facility are marked NA. The facility generally met 

requirements. We made no recommendations. 

NM Areas Reviewed Findings 

Patients’ post-discharge needs were identified, 

and discharge planning addressed the 

identified needs. 

Clinicians provided discharge instructions to 

patients and/or caregivers and validated their 

understanding. 

Patients received the ordered aftercare 

services and/or items within the 

ordered/expected timeframe. 

Patients’ and/or caregivers’ knowledge and 

learning abilities were assessed during the 

inpatient stay. 

The facility complied with any additional 

elements required by VHA or local policy. 

VA OIG Office of Healthcare Inspections 9 
CAP Review of the Grand Junction VA Medical Center, Grand Junction, CO 

AIS Care 

The purpose of this review was to determine whether the facility complied with selected 

requirements for the assessment and treatment of patients who had an AIS.e 

We reviewed relevant documents and the EHRs of 12 patients who experienced stroke 

symptoms, and we conversed with key employees. We also conducted onsite inspections of the 

ED, one critical care unit, and four inpatient units. The table below shows the areas reviewed 

for this topic. The areas marked as NM did not meet applicable requirements and needed 

improvement. Any items that did not apply to this facility are marked NA. 

NM Areas Reviewed Findings 

X The facility’s stroke policy/plan/guideline 

addressed all required items. 

 The facility did not have a policy in place 

addressing the management of AIS. 

X Clinicians completed the National Institutes of 

Health stroke scale for each patient within the 

expected timeframe. 

 None of the EHRs contained documented 

evidence of completed stroke scales. 

NA Clinicians provided medication (tPA) timely to 

halt the stroke and included all required steps, 

and tPA was in stock or available within 

15 minutes. 

X Stroke guidelines were posted in all areas 

where patients may present with stroke 

symptoms. 

 Stroke guidelines were not posted in the ED 

or on any of the five units. 

X Clinicians screened patients for difficulty 

swallowing prior to oral intake of food or 

medicine. 

 Five of the 11 applicable EHRs did not 

contain documentation that patients were 

screened for difficulty swallowing prior to oral 

intake. 

X Clinicians provided printed stroke education to 

patients upon discharge. 

 Eight of the 10 applicable EHRs did not 

contain documentation that stroke education 

was provided to the patient/caregiver. 

NA The facility provided training to staff involved 

in assessing and treating stroke patients. 

X The facility collected and reported required 

data related to stroke care. 

 There was no evidence that the following data 

were collected and/or reported to VHA: 

o Percent of eligible patients given tPA 

o Percent of patients with stroke symptoms 

who had the stroke scale completed 

o Percent of patients screened for difficulty 

swallowing before oral intake. 

The facility complied with any additional 

elements required by VHA or local policy. 

Recommendations 

7. We recommended that the facility develop an acute ischemic stroke policy that addresses 

all required items, that the policy be fully implemented, and that compliance be monitored. 

VA OIG Office of Healthcare Inspections 10 
CAP Review of the Grand Junction VA Medical Center, Grand Junction, CO 

8. We recommended that processes be strengthened to ensure that clinicians complete and 

document National Institutes of Health stroke scales for each stroke patient and that compliance 

be monitored. 

9. We recommended that stroke guidelines be posted in the emergency department, on the 

critical care unit, and on all inpatient units. 

10. We recommended that processes be strengthened to ensure that clinicians screen patients 

for difficulty swallowing prior to oral intake. 

11. We recommended that processes be strengthened to ensure that clinicians provide printed 

stroke education to patients upon discharge and that compliance be monitored. 

12. We recommended that the facility collect and report to VHA the percent of eligible patients 

given tissue plasminogen activator, the percent of patients with stroke symptoms who had the 

stroke scale completed, and the percent of patients screened for difficulty swallowing before oral 

intake. 

VA OIG Office of Healthcare Inspections 11 
 

CAP Review of the Grand Junction VA Medical Center, Grand Junction, CO 

CLC Resident Independence and Dignity 

The purpose of this review was to determine whether the facility provided CLC restorative 

nursing services and complied with selected nutritional management and dining service 

requirements to assist CLC residents in maintaining their optimal level of functioning, 

independence, and dignity.f 

We reviewed six EHRs of residents (five residents receiving restorative nursing services and 

one resident not receiving restorative nursing services but a candidate for services). 

We also observed one resident during two meal periods, reviewed two employee 

training/competency records and other relevant documents, and conversed with key employees. 

The table below shows the areas reviewed for this topic. The area marked as NM did not meet 

applicable requirements and needed improvement. Any items that did not apply to this facility 

are marked NA. 

NM Areas Reviewed Findings 

The facility offered restorative nursing 

services. 

Facility staff completed and documented 

restorative nursing services, including active 

and passive range of motion, bed mobility, 

transfer, and walking activities, according to 

clinician orders and residents’ care plans. 

Resident progress towards restorative nursing 

goals was documented, and interventions 

were modified as needed to promote the 

resident’s accomplishment of goals. 

When restorative nursing services were care 

planned but were not provided or were 

discontinued, reasons were documented in 

the EHR. 

If residents were discharged from physical 

therapy, occupational therapy, or 

kinesiotherapy, there was hand-off 

communication between Physical Medicine 

and Rehabilitation Service and the CLC to 

ensure that restorative nursing services 

occurred. 

Training and competency assessment were 

completed for staff who performed restorative 

nursing services. 

X The facility complied with any additional 

elements required by VHA or local policy. 

Facility policy on CLC Restorative Nursing 

Program reviewed: 

 The Restorative Care Coordinator did not 

consistently document patient restorative 

program goals and progress weekly in any of 

the five applicable EHRs. 

VA OIG Office of Healthcare Inspections 12 
CAP Review of the Grand Junction VA Medical Center, Grand Junction, CO 

NM Areas Reviewed for Assistive Eating 

Devices and Dining Service 

Findings 

Care planned/ordered assistive eating devices 

were provided to residents at meal times. 

Required activities were performed during 

resident meal periods. 

The facility complied with any additional 

elements required by VHA or local policy. 

Recommendation 

13. We recommended that processes be strengthened to ensure that the Restorative Care 

Coordinator documents patient restorative program goals and progress weekly in accordance 

with facility policy and that compliance be monitored. 

VA OIG Office of Healthcare Inspections 13 
 

    

 

CAP Review of the Grand Junction VA Medical Center, Grand Junction, CO 

MRI Safety 

The purpose of this review was to determine whether the facility ensured safety in MRI 

in accordance with VHA policy requirements related to: (1) staff safety training, 

(2) patient screening, and (3) risk assessment of the MRI environment.g 

We reviewed relevant documents and the training records of 32 employees (28 randomly 

selected Level 1 ancillary staff and 4 designated Level 2 MRI personnel), and we conversed 

with key managers and employees. We also reviewed the EHRs of 35 randomly selected 

patients who had an MRI January 1–December 31, 2013. Additionally, we conducted a physical 

inspection of one MRI area. The table below shows the areas reviewed for this topic. 

The area marked as NM did not meet applicable requirements and needed improvement. 

Any items that did not apply to this facility are marked NA. 

NM Areas Reviewed Findings 

The facility completed an MRI risk 

assessment, there were documented 

procedures for handling emergencies in MRI, 

and emergency drills were conducted in the 

MRI area. 

X Two patient safety screenings were conducted 

prior to MRI, and the secondary patient safety 

screening form was signed by the patient, 

family member, or caregiver and reviewed and 

signed by a Level 2 MRI personnel. 

 None of the EHRs contained initial patient 

safety screenings. 

 Thirty-three EHRs (94 percent) did not contain 

secondary patient safety screenings prior to 

MRI; therefore, we were unable to determine 

whether any contraindications were 

addressed. 

 Neither of the two secondary patient safety 

screening forms were signed by a Level 2 

MRI personnel prior to MRI. 

Any MRI contraindications were noted on the 

secondary patient safety screening form, and 

a Level 2 MRI personnel and/or radiologist 

addressed the contraindications and 

documented resolution prior to MRI. 

Level 1 ancillary staff and Level 2 MRI 

personnel were designated and received 

level-specific annual MRI safety training. 

Signage and barriers were in place to prevent 

unauthorized or accidental access to Zones III 

and IV. 

MRI technologists maintained visual contact 

with patients in the magnet room and two-way 

communication with patients inside the 

magnet, and the two-way communication 

device was regularly tested. 

Patients were offered MRI-safe hearing 

protection for use during the scan. 

VA OIG Office of Healthcare Inspections 14 
CAP Review of the Grand Junction VA Medical Center, Grand Junction, CO 

NM Areas Reviewed (continued) Findings 

The facility had only MRI-safe or compatible 

equipment in Zones III and IV, or the 

equipment was appropriately protected from 

the magnet. 

The facility complied with any additional 

elements required by VHA or local policy. 

Recommendations 

14. We recommended that processes be strengthened to ensure that initial patient safety 

screenings are conducted and documented in patients’ electronic health records and that 

compliance be monitored. 

15. We recommended that processes be strengthened to ensure that secondary patient safety 

screenings are completed immediately prior to magnetic resonance imaging and placed in 

patients’ electronic health records, that any contraindications are identified and resolution 

documented prior to the scan, that Level 2 personnel conducting the secondary screenings sign 

the forms prior to the scan, and that compliance be monitored. 

VA OIG Office of Healthcare Inspections 15 
 

CAP Review of the Grand Junction VA Medical Center, Grand Junction, CO 

Review Activity with Previous CAP Recommendations 

Follow-Up on CRC Screening 

As a follow-up to recommendations from our previous CAP review, we attempted to reassess 

facility compliance with CRC screening;h

 however, the facility was unable to provide evidence of 

sustained compliance for any of the requirements below. 

Positive CRC Screening Test Result Notification. VHA requires that patients receive notification 

of CRC screening test results within 14 days of the laboratory receipt date for fecal occult blood 

tests or the test date for sigmoidoscopy or double contrast barium enema and that clinicians 

document notification. 

Follow-Up in Response to Positive CRC Screening Test. For any positive CRC screening test, 

VHA requires responsible clinicians to either document a follow-up plan or document that 

no follow-up is indicated within 14 days of the screening test. 

Diagnostic Testing Timeliness. VHA requires that patients receive diagnostic testing within 

60 days of positive CRC screening test results unless contraindicated. 

Diagnostic Test Result Notification. VHA requires that test results be communicated to patients 

no later than 14 days from the date on which the results are available to the ordering practitioner 

and that clinicians document notification. 

Biopsy Result Notification. VHA requires that patients who have a biopsy receive notification 

within 14 days of the date the biopsy results were confirmed and that clinicians document 

notification. 

Recommendation 

16. We recommended that the facility implement processes to monitor compliance with 

colorectal cancer timeliness and patient notification requirements. 

VA OIG Office of Healthcare Inspections 16 
 

 

CAP Review of the Grand Junction VA Medical Center, Grand Junction, CO 

Appendix A 

Facility Profile (Grand Junction/575) FY 2014 through 

June 20141 

Type of Organization Secondary 

Complexity Level 2-Medium complexity 

Affiliated/Non-Affiliated Affiliated 

Total Medical Care Budget in Millions $98.9 

Number (as of July 2014) of: 

 Unique Patients 13,046 

 Outpatient Visits 143,021 

 Unique Employees2 501 

Type and Number of Operating Beds: 

 Hospital 31 

 CLC 30 

 MH NA 

Average Daily Census: 

 Hospital 17 

 CLC 25 

 MH NA 

Number of Community Based Outpatient Clinics 2 

Location(s)/Station Number(s) Montrose/575GA 

Craig/575GB 

VISN Number 19 

1

 All data is for FY 2014 through June 2014 except where noted. 

2

 Unique employees involved in direct medical care (cost center 8200). 

VA OIG Office of Healthcare Inspections 17 
CAP Review of the Grand Junction VA Medical Cen

Strategic Analytics for Improvement and Learning (SAIL)3 

3 Metric definitions follow the graphs. 

VA OIG Office of Healthcare Inspections 
CAP Review of the Grand Junction VA Med

Scatter Chart 

VA OIG Office of Healthcare Inspections 
CAP Review of the Grand Junction VA Med

Metric Definitions 

Measure Definition Desired direc

ACSC Hospitalization Ambulatory care sensitive condition hospitalizations (observed to expected ratio) A lower value 

Adjusted LOS Acute care risk adjusted length of stay A lower value 

Best Place to Work Overall satisfaction with job A higher value 

Call Center Responsiveness Average speed of call center responded to calls in seconds A lower value 

Call Responsiveness Call center speed in picking up calls and telephone abandonment rate A lower value 

Complications Acute care risk adjusted complication ratio A lower value 

Efficiency Overall efficiency measured as 1 divided by SFA (Stochastic Frontier Analysis) A higher value 

Employee Satisfaction Overall satisfaction with job A higher value 

HC Assoc Infections Health care associated infections A lower value 

HEDIS Outpatient performance measure (HEDIS) A higher value 

MH Status MH status (outpatient only, the Veterans RAND 12 Item Health Survey) A higher value 

MH Wait Time MH wait time for new and established patients (top 50 clinics; FY13 and later) A higher value 

Oryx Inpatient performance measure (ORYX) A higher value 

Physical Health Status Physical health status (outpatient only, the Veterans RAND 12 item Health Survey) A higher value 

Primary Care Wait Time Primary care wait time for new and established patients (top 50 clinics; FY13 and later) A higher value 

PSI Patient safety indicator (observed to expected ratio) A lower value 

Pt Satisfaction Overall rating of hospital stay (inpatient only) A higher value 

RN Turnover Registered nurse turnover rate A lower value 

RSMR-AMI 30-day risk standardized mortality rate for acute myocardial infarction A lower value 

RSMR-CHF 30-day risk standardized mortality rate for congestive heart failure A lower value 

RSMR-Pneumonia 30-day risk standardized mortality rate for pneumonia A lower value 

RSRR-AMI 30-day risk standardized readmission rate for acute myocardial infarction A lower value 

RSRR-CHF 30-day risk standardized readmission rate for congestive heart failure A lower value 

RSRR-Pneumonia 30-day risk standardized readmission rate for pneumonia A lower value 

SMR Acute care in-hospital standardized mortality ratio A lower value 

SMR30 Acute care 30-day standardized mortality ratio A lower value 

Specialty Care Wait Time Specialty care wait time for new and established patients (top 50 clinics; FY13 and later) A higher value 

VA OIG Office of Healthcare Inspections 
CAP Review of the Grand Junction VA Medical Center, Grand Junction, CO 

Appendix C 

Acting VISN Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: August 15, 2014 

From: Acting Director, Rocky Mountain Network (10N19) 

Subject: CAP Review of the Grand Junction VA Medical Center, 

Grand Junction, CO 

To: Director, Dallas Office of Healthcare Inspections (54DA) 

Director, Management Review Service (VHA 10AR MRS 

OIG CAP CBOC) 

I have reviewed and concur on the submitted responses to the 

Grand Junction VAMC OIG CAP Draft Report. If you have any further 

questions please contact Ms. Susan Curtis, VISN 19 HSS (303) 639-6995.
 

Signed for and in the absence of: 

Ralph T. Gigliotti, FACHE 

Director, Rocky Mountain Network (10N19) 

VA OIG Office of Healthcare Inspections 21 
 

CAP Review of the Grand Junction VA Medical Center, Grand Junction, CO 

Appendix D 

Facility Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: August 11, 2014 

From: Director, Grand Junction VA Medical Center (575/00) 

Subject: CAP Review of the Grand Junction VA Medical Center, 

Grand Junction, CO 

To: Director, Rocky Mountain Network (10N19) 

1. Thank you for the opportunity to submit responses to the 

proposed recommendations for the Grand Junction VA Medical Center, 

Grand Junction, CO. 

2. I have reviewed and concur with the sixteen (16) findings and 

recommendations in the report of the Office of Inspector General 

conducted the week of July 7, 2014. 

3. Corrective action plans and compliance monitoring have been 

established and target completion dates have been set for the 

recommendations as detailed in the attached report. 

4. If you have additional questions or need further information, 

please contact Michelle Ernzen, Chief, Quality Management, at 

(970) 242-0731, x2873. 

VA OIG Office of Healthcare Inspections 22 
 

CAP Review of the Grand Junction VA Medical Center, Grand Junction, CO 

Comments to OIG’s Report 

The following Director’s comments are submitted in response to the recommendations 

in the OIG report: 

OIG Recommendations 

Recommendation 1. We recommended that the Medical Executive Committee discuss 

and document its approval of the use of another facility’s providers for teledermatology 

services. 

Concur 

Target date for completion: October 31, 2014 

Facility response: The teledermatology service agreement will be discussed at the 

September Clinical Executive Board meeting. Discussions and approval of services will 

be documented in the meeting minutes. 

Recommendation 2. We recommended that processes be strengthened to ensure that 

continuing stay reviews are consistently performed on at least 75 percent of patients 

in acute beds. 

Concur 

Target date for completion: October 31, 2014 

Facility response: The facility hired and trained a Quality Management Specialist 

(January 2014) who has primary responsibilities for performing and communicating 

continued stay reviews. Additionally, another QM Specialist has been trained to 

complete the reviews, thus providing continued coverage during planned and unplanned 

absences. Since March 2014, the facility has achieved >95% compliance on the 

continued stay reviews. Compliance monitoring will occur quarterly through the UM 

report to the Clinical Executive Board. 

Recommendation 3. We recommended that processes be strengthened to ensure that 

the quality of entries in the electronic health record is reviewed. 

Concur 

Target date for completion: June 30, 2015 

Facility response: Service Chiefs, Supervisors, and Administrative Officers received 

training on the process for performing quality record reviews and reporting requirements 

to the Medical Record Committee. Quality Management developed and distributed a 

Microsoft Excel workbook to aid services in compiling and reporting the quality record 

reviews to the committee. The Medical Record Committee will develop and distribute a 

VA OIG Office of Healthcare Inspections 23 
 

 

 

CAP Review of the Grand Junction VA Medical Center, Grand Junction, CO 

reporting grid that outlines when services are scheduled to report their quality record 

reviews to the committee. Quality data not meeting the identified performance standard 

will require action plans for submission to committee for review and analysis. 

Compliance will be monitored through the Medical Record Committee. 

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

the Blood Usage Review Committee member from Anesthesia Service consistently 

attends meetings. 

Concur 

Target date for completion: December 31, 2014 

Facility response: The Section Chief, Anesthesia, has been assigned as the permanent 

member of the Blood Utilization Committee. During his absence, another Anesthesia 

provider will attend the meetings. 

Recommendation 5. We recommended that nurse call systems be installed in the 

emergency department. 

Concur 

Target date for completion: June 30, 2015 

Facility response: GJVAMC concurs with the recommendation to install a nurse call 

system in the Emergency Department. By December 31, 2014, a request for funding 

will be uploaded to the VISN 19 Capital Asset Manager (CAM) for the design and 

installation of the nurse call systems. Award of the project is expected by 

March 31, 2015. Interim measures are in place and include bedside hand bells and 

increased staff presence. 

Recommendation 6. We recommended that processes be strengthened to ensure that 

multi-dose medication vials are dated when opened and expired medications 

are promptly removed from patient care areas and that compliance be monitored. 

Concur 

Target date for completion: December 31, 2014 

Facility response: By August 31, 2014, the Medication Management Policy 

(MCM 119-3) will be revised to reflect the need for expired medications to be promptly 

removed from patient care areas. Patient Care Services staff will be re-educated 

on the policy and procedures required for safe medication management by 

September 30, 2014. Additionally, the expiration date review has been added to the 

“Daily Checklist” for all patient care areas, and as a result, all MDV will be checked for 

expiration on a daily basis (on days the unit is open; i.e. Outpatient Clinics that work 

Monday–Friday will not have the checklist completed on weekends, as there are no 

patients or staff in those areas during the weekend). The Associate Chief Nurse 

VA OIG Office of Healthcare Inspections 24 
 

 

 

CAP Review of the Grand Junction VA Medical Center, Grand Junction, CO 

(ACNS) assigned to each unit will be responsible for monitoring compliance via review 

of the Daily Checklists. Compliance will also be monitored during EOC rounds. 

Recommendation 7. We recommended that the facility develop an acute ischemic 

stroke policy that addresses all required items, that the policy be fully implemented, and 

that compliance be monitored. 

Concur 

Target date for completion: December 31, 2014 

Facility response: A small interdisciplinary team has been formed and is developing a 

policy defining the treatment of Acute Ischemic Stroke (AIS) for a Supporting Stroke 

Facility as required by VHA Directive by September 30, 2014. Education of staff will be 

completed by October 31, 2014. Compliance monitoring will be accomplished through 

the AIS quality indicator monitoring and reported quarterly to the Critical Care 

Committee. 

Recommendation 8. We recommended that processes be strengthened to ensure that 

clinicians complete and document National Institutes of Health stroke scales for each 

stroke patient and that compliance be monitored. 

Concur 

Target date for completion: March 31, 2015 

Facility response: An NIH template note is being developed for documentation of the 

NIH stroke scale. The note will be free-standing for clinical staff to complete when 

indicated and will be incorporated into the Emergency Department triage note. 

The template note and staff training will occur by October 31, 2014. 

Compliance monitoring of the use of the NIH stroke scale will be accomplished through 

the AIS quality indicator monitoring and reported to the Critical Care Committee. 

Recommendation 9. We recommended that stroke guidelines be posted in the 

emergency department, on the critical care unit, and on all inpatient units. 

Concur 

Target date for completion: October 31, 2014 

Facility response: Stroke guidelines for recognition and treatment of AIS will be posted 

in the outpatient clinics, inpatient wards, Community Living Center, and the Emergency 

Department by October 31, 2014. In addition, stroke guideline badge buddies have 

been ordered and will be distributed to clinical staff. 

VA OIG Office of Healthcare Inspections 25 
 

 

CAP Review of the Grand Junction VA Medical Center, Grand Junction, CO 

Recommendation 10. We recommended that processes be strengthened to ensure 

that clinicians screen patients for difficulty swallowing prior to oral intake. 

Concur 

Target date for completion: March 31, 2015 

Facility response: Nursing Patient Care Memorandum 003-50, Stroke Patient Nursing 

Swallow Screen has been in place since March 2013. Nursing staff will be re-educated 

on the dysphagia screening by October 31, 2014. Compliance monitoring of the 

dysphagia screening will be accomplished through the AIS quality indicator monitoring 

and reported to the Critical Care Committee. 

Recommendation 11. We recommended that processes be strengthened to ensure 

that clinicians provide printed stroke education to patients upon discharge and that 

compliance be monitored. 

Concur 

Target date for completion: March 31, 2015 

Facility response: Education Service will identify select stroke education materials that 

will be available for Veterans. Educational material will be added to the tools section in 

CPRS so staff can print and provide to patients on discharge. Reminder dialogue will 

be added to the Education Note for staff to document the specific handout that was 

provided to the Veteran/Caregiver. Training of staff will occur by October 31, 2014. 

Compliance monitoring of documentation of printed materials will be accomplished 

through the AIS quality indicator monitoring process and reported to the Critical Care 

Committee. 

Recommendation 12. We recommended that the facility collect and report to VHA the 

percent of eligible patients given tissue plasminogen activator, the percent of patients 

with stroke symptoms who had the stroke scale completed, and the percent of patients 

screened for difficulty swallowing before oral intake. 

Concur 

Target date for completion: December 31, 2014 

Facility response: A QM Specialist has been identified to collect and report Acute 

Ischemic Stroke quality indicators. Training on the quality indicator data collection and 

data analysis will occur by September 30, 2014. Quality indicator data will be presented 

quarterly to the Critical Care Committee (CCC). Discussion and recommended 

improvement actions will be documented in the CCC minutes. 

VA OIG Office of Healthcare Inspections 26 
CAP Review of the Grand Junction VA Medical Center, Grand Junction, CO 

Recommendation 13. We recommended that processes be strengthened to ensure 

that the Restorative Care Coordinator documents patient restorative program goals and 

progress weekly in accordance with facility policy and that compliance be monitored. 

Concur 

Target date for completion: January 31, 2015 

Facility response: The unit specific memorandum (USM) 003T-24, Community Living 

Center Restorative Nursing Program, will be revised to reflect a monthly assessment of 

the restorative goals that is documented in CPRS. The USM changes will be completed 

by September 30, 2014. The Restorative Care Nurse will be placed on the work 

schedule for administrative time for a minimum of 4–8 hours a month to complete 

documentation and any other administrative duties for the Restorative Care program. 

Monthly compliance monitoring will be done by the Associate Chief Nurse and reported 

to the CLC Steering Committee. 

Recommendation 14. We recommended that processes be strengthened to ensure 

that initial patient safety screenings are conducted and documented in patients’ 

electronic health records and that compliance be monitored. 

Concur 

Target date for completion: December 31, 2014 

Facility response: MRI primary and secondary patient safety screens are on the same 

piece of paper. Primary screen will be completed by the radiology scheduler at the time 

MRI is scheduled. Education has been completed with staff regarding the necessity for 

legible full signature (first and last name) and date. Signature requirements include 

both staff members and patient/caregiver. Provider order sets for MRI ordering will be 

changed to include primary safety screening questions. Radiology Supervisor will do a 

100% review of safety screens beginning July 1, 2014, and continuing through the end 

of September 2014. Following the end of the 90 day 100% review, the Radiology 

Supervisor will do random audits and report results to the MRI Safety Committee on a 

quarterly basis. 

Recommendation 15. We recommended that processes be strengthened to ensure 

that secondary patient safety screenings are completed immediately prior to magnetic 

resonance imaging and placed in patients’ electronic health records, that 

any contraindications are identified and resolution documented prior to the scan, 

that Level 2 personnel conducting the secondary screenings sign the forms prior to the 

scan, and that compliance be monitored. 

Concur 

Target date for completion: December 31, 2014 

VA OIG Office of Healthcare Inspections 27 
CAP Review of the Grand Junction VA Medical Center, Grand Junction, CO 

Facility response: Secondary screen will be completed by the MRI Tech on the same 

day of the scan immediately prior to beginning the scan. Education has been 

completed with staff regarding the necessity for legible full signature (first and last 

name) and date. Signature requirements include both staff members and 

patient/caregiver. Radiologist, Radiology Supervisor and Clinic Application Coordinator 

will develop CPRS changes to assist with the identification and resolution of 

contraindications identified on the safety screen. These changes will be put into place 

by August 31, 2014, and include: MRI contraindications note title in CPRS, to be used 

by the Radiologist and/or Level 2 MRI personnel for documenting contraindications and 

resolution. Radiology Supervisor will run a quarterly list of “contraindication note titles” 

and audit those charts for resolution and appropriate documentation. Results will be 

reported to the MRI Safety Committee on a quarterly basis. 

Recommendation 16. We recommended that the facility implement processes to 

monitor compliance with colorectal cancer timeliness and patient notification 

requirements. 

Concur 

Target date for completion: December 31, 2014 

Facility response: The Endoscopy Nurse role has been modified to a Case 

Management model. The Endoscopy Nurse is responsible for monitoring all aspects of 

the colorectal cancer screening process for all FOBT+ Veterans and communicating 

with providers as indicated. Tracking of all FOBT+ Veterans started in July 2014. 

Primary Care and Surgery providers will be educated on documentation of patient 

notification of test results and follow up plan by September 30, 2014. Compliance 

monitoring will be done by the Endoscopy Nurse and reported quarterly to the 

Invasive/Operative Committee. 

VA OIG Office of Healthcare Inspections 28 
CAP Review of the Grand Junction VA Medical Center, Grand Junction, CO 

Appendix E 

OIG Contact and Staff Acknowledgments 

Contact For more information about this report, please contact the OIG 

at (202) 461-4720. 

Onsite Trina Rollins, MS, PA-C, Team Leader 

Contributors Gayle Karamanos, MS, PA-C 

Cathleen King, MHA, CRRN 

Annette Nowak, Office of Investigations 

Other 

Contributors 

Elizabeth Bullock 

Shirley Carlile, BA 

Paula Chapman, CTRS 

Lin Clegg, PhD 

Marnette Dhooghe, MS 

Jeff Joppie, BS 

Misti Kincaid, BS 

Nathan McClafferty, MS 

Larry Ross, MS 

Patrick Smith, M. Stat 

Julie Watrous, RN, MS 

Jarvis Yu, MS 

VA OIG Office of Healthcare Inspections 29 
CAP Review of the Grand Junction VA Medical Center, Grand Junction, CO 

Appendix F 

Report Distribution 

VA Distribution 

Office of the Secretary 

VHA 

Assistant Secretaries 

General Counsel 

Director, Rocky Mountain Network (10N19) 

Director, Grand Junction VA Medical Center (575/00) 

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: Michael F. Bennet, Orrin G. Hatch, Mike Lee, Mark Udall 

U.S. House of Representatives: Jason Chaffetz, Scott Tipton 

This report is available at www.va.gov/oig. 

VA OIG Office of Healthcare Inspections 30 
 

 

 

 

 

 

 

 

 

 

CAP Review of the Grand Junction VA Medical Center, Grand Junction, CO 

Appendix G 

Endnotes 

a

 References used for this topic included:
 

 VHA Directive 2009-043, Quality Management System, September 11, 2009. 

 VHA Handbook 1050.01, VHA National Patient Safety Improvement Handbook, March 4, 2011. 

 VHA Directive 2010-017, Prevention of Retained Surgical Items, April 12, 2010. 

 VHA Directive 2010-025, Peer Review for Quality Management, June 3, 2010. 

 VHA Directive 2010-011, Standards for Emergency Departments, Urgent Care Clinics, and Facility Observation 

Beds, March 4, 2010. 

 VHA Directive 2009-064, Recording Observation Patients, November 30, 2009. 

 VHA Handbook 1100.19, Credentialing and Privileging, October 15, 2012. 

 VHA Directive 2008-063, Oversight and Monitoring of Cardiopulmonary Resuscitative Events and Facility 

Cardiopulmonary Resuscitation Committees, October 17, 2008. 

 VHA Handbook 1907.01, Health Information Management and Health Records, September 19, 2012. 

 VHA Directive 6300, Records Management, July 10, 2012. 

 VHA Directive 2009-005, Transfusion Utilization Committee and Program, February 9, 2009. 

 VHA Handbook 1106.01, Pathology and Laboratory Medicine Service Procedures, October 6, 2008. b

 References used for this topic included: 

 VHA Directive 2011-007, Required Hand Hygiene Practices, February 16, 2011. 

 VHA Handbook 1121.01, VHA Eye Care, March 10, 2011. 

 VA National Center for Patient Safety, “Multi-Dose Pen Injectors,” Patient Safety Alert 13-04, January 17, 2013. 

 “Adenovirus-Associated Epidemic Keratoconjunctivitis Outbreaks –Four States, 2008–2010,” Centers for Disease 

Control and Prevention Morbidity and Mortality Weekly Report, August 16, 2013. 

	 Various requirements of The Joint Commission, the Occupational Safety and Health Administration, the 

American National Standards Institute/Advancing Safety in Medical Technology, the Centers for Disease Control 

and Prevention, the International Association of Healthcare Central Service Materiel Management ,the National 

Fire Protection Association, the Health Insurance Portability and Accountability Act, Underwriters Laboratories. c

 References used for this topic included:
 

 VHA Handbook 1108.06, Inpatient Pharmacy Services, June 27, 2006.
 

 VHA Handbook 1108.05, Outpatient Pharmacy Services, May 30, 2006. 

 VHA Directive 2011-012, Medication Reconciliation, March 9, 2011.
 

 VHA Handbook 1907.01, Health Information Management and Health Records, September 19, 2012. 

 Manufacturer’s instructions for Cipro® and Levaquin®.
 

 Various requirements of The Joint Commission.
 d

 References used for this topic included:
 

 VHA Handbook 1120.04, Veterans Health Education and Information Core Program Requirements, 

July 29, 2009. 

 VHA Handbook 1907.01, Health Information Management and Health Records, September 19, 2012. 

 The Joint Commission, Comprehensive Accreditation Manual for Hospitals, July 2013. e

 The references used for this topic were: 

 VHA Directive 2011-038, Treatment of Acute Ischemic Stroke, November 2, 2011. 

 Guidelines for the Early Management of Patients with Acute Ischemic Stroke (AHA/ASA Guidelines), 

January 31, 2013. f

 References used for this topic included: 

 VHA Handbook 1142.01, Criteria and Standards for VA Community Living Centers (CLC), August 13, 2008. 

 VHA Handbook 1142.03, Requirements for Use of the Resident Assessment Instrument (RAI) Minimum Data Set 

(MDS), January 4, 2013. 

 Centers for Medicare and Medicaid Services, Long-Term Care Facility Resident Assessment Instrument User’s 

Manual, Version 3.0, May 2013. 

 VHA Manual M-2, Part VIII, Chapter 1, Physical Medicine and Rehabilitation Service, October 7, 1992. 

 Various requirements of The Joint Commission. 

VA OIG Office of Healthcare Inspections 31 
 

CAP Review of the Grand Junction VA Medical Center, Grand Junction, CO 

g

 References used for this topic included: 

	 VHA Handbook 1105.05, Magnetic Resonance Imaging Safety, July 19, 2012. 

	 Emanuel Kanal, MD, et al., “ACR Guidance Document on MR Safe Practices: 2013,” Journal of Magnetic 

Resonance Imaging, Vol. 37, No. 3, January 23, 2013, pp. 501–530. 

	 The Joint Commission, “Preventing accidents and injuries in the MRI suite,” Sentinel Event Alert, Issue 38, 

February 14, 2008. 

	 VA National Center for Patient Safety, “MR Hazard Summary,” 

http://www.patientsafety.va.gov/professionals/hazards/mr.asp. 

	 VA Radiology, “Online Guide,” http://vaww1.va.gov/RADIOLOGY/OnLine_Guide.asp, updated 

October 4, 2011. h

 The references used for this topic were: 

	 VHA Directive 2007-004, Colorectal Cancer Screening, January 12, 2007 (corrected copy). 

	 VHA Directive 2009-019, Ordering and Reporting Test Results, March 24, 2009. 

VA OIG Office of Healthcare Inspections 32