Department of Veterans Affairs

Office of Inspector General

Office of Healthcare Inspections

Report No. 08-02602-140

Combined Assessment Program 

Review of the 

VA Illiana Health Care System 

Danville, Illinois 

June 3, 2009

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 fraud and integrity awareness training 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 

Call the OIG Hotline – (800) 488-8244
Combined Assessment Program Review of the VA Illiana Health Care System, Danville, Illinois 

Table of Contents 

Page 

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

Introduction ................................................................................................................ 1

Profile...................................................................................................................... 1

Objectives and Scope ............................................................................................. 2

Organizational Strength............................................................................................. 3

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

Review Activities With Recommendations .............................................................. 3

Quality Management Program........................................................................... 3

Environment of Care.......................................................................................... 5

Coordination of Care ......................................................................................... 7

Emergency/Urgent Care Operations ................................................................. 8

Suicide Prevention Program.............................................................................. 10

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

Medication Management ................................................................................... 11

Survey of Healthcare Experiences of Patients .................................................. 12

Appendixes

A. VISN Director Comments .................................................................................. 14

B. System Director Comments............................................................................... 15

C. OIG Contact and Staff Acknowledgments ......................................................... 19

D. Report Distribution............................................................................................. 20

VA Office of Inspector General 
Combined Assessment Program Review of the VA Illiana Health Care System, Danville, Illinois 

Executive Summary 

Introduction During the week of March 16–20, 2009, the OIG conducted a 

Combined Assessment Program (CAP) review of the VA 

Illiana Health Care System (the system), Danville, IL. The 

purpose of the review was to evaluate selected operations, 

focusing on patient care administration and quality 

management (QM). During the review, we also provided 

fraud and integrity awareness training to 403 system 

employees. The system is part of Veterans Integrated 

Service Network (VISN) 11. 

Results of the 

Review 

The CAP review covered seven operational activities. We 

identified the following organizational strength and reported 

accomplishment: 

• The system received recognition from the National Center 

for Patient Safety (NCPS). 

We made recommendations in five of the activities reviewed. 

One environment of care (EOC) finding was a repeat finding 

from our prior CAP review. For these activities, the system 

needed to: 

• Ensure that clinical privileges granted to contractors do not 

extend beyond the contract period. 

• Ensure that managers fully implement the mechanism 

established to track cardiopulmonary resuscitation (CPR) 

and Advanced Cardiac Life Support (ACLS) training 

compliance and ensure that employees complete the 

training. 

• Correct identified cleanliness, pest control, infection control 

(IC), and patient safety issues. 

• Establish effective processes to ensure that EOC 

deficiencies are identified and resolved. 

• Ensure that consultation responses are received within the 

timeframe specified by system policy. 

• Ensure that active outpatient medications are correctly 

listed in all discharge documentation. 

• Ensure that emergency room (ER) physicians do not have 

responsibilities outside of the ER, in accordance with 

Veterans Health Administration (VHA) policy. 

VA Office of Inspector General i
Combined Assessment Program Review of the VA Illiana Health Care System, Danville, Illinois 

• Ensure that all inter-facility transfer documentation is in 

compliance with VHA and system policy. 

• Ensure that medical record documentation for patients 

deemed at high risk for suicide is in compliance with VHA 

regulations and system policy. 

The system complied with selected standards in the following 

two activities: 

• Medication Management. 

• Survey of Healthcare Experiences of Patients (SHEP). 

This report was prepared under the direction of 

Verena Briley-Hudson, Director, Chicago and Kansas City 

Offices of Healthcare Inspections. 

Comments The VISN and System Directors agreed with the CAP review 

findings and recommendations and provided acceptable 

improvement plans. (See Appendixes A and B, 

pages 14–18, for the full text of the Directors’ comments). 

We will follow up on the planned actions until they are 

completed. 

 (original signed by:)

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

Assistant Inspector General for 

Healthcare Inspections 

VA Office of Inspector General ii
Combined Assessment Program Review of the VA Illiana Health Care System, Danville, Illinois 

VA Office of Inspector General 1 

Introduction 

Profile Organization. The system is an acute and long-term care 

facility located in Danville, IL, that provides a broad range of 

inpatient and outpatient health care services. Outpatient 

care is also provided at four community based outpatient 

clinics (CBOCs) in Decatur, Peoria, and Springfield, IL, and 

in West Lafayette, IN. The system is part of VISN 11 and 

serves a veteran population of about 147,000 throughout 

central Illinois and west central Indiana. 

Programs. The system provides acute and sub-specialty 

medicine, surgery, mental health (MH), community living 

center (CLC),1

 palliative care, women’s health, substance 

abuse, rehabilitation, and ambulatory care services. It has 

129 hospital beds and 217 CLC beds. 

Affiliations and Research. The system is affiliated with 

the University of Illinois’ Colleges of Medicine at 

Urbana-Champaign and at Peoria and with Indiana 

University’s School of Optometry and provides training for 

45 medical residents. It also provides training for other 

disciplines, including audiology and speech pathology, 

dietetics, dental hygiene, music therapy, psychology, 

radiology, social work, technology, and therapeutic 

recreation. In fiscal year (FY) 2008, the system’s research 

program had five protocols that were managed within the 

existing system budget. Important areas of research 

included diabetes, peripheral vascular disease, glaucoma, 

and nursing orientation. 

Resources. In FY 2008, medical care expenditures totaled 

approximately $131.7 million. The FY 2009 medical care 

budget is approximately $181 million. FY 2008 staffing was 

1,233 full-time employee equivalents (FTE), including 

54 physician and 215 nursing FTE. 

Workload. In FY 2008, the system treated 30,976 unique 

patients and provided 15,988 inpatient days in the hospital 

and 56,861 inpatient days in the CLC. The inpatient care 

workload totaled 3,137 discharges, and the average daily 

census, including CLC patients, was 202. Outpatient 

workload totaled 253,253 visits. 

 

1

 A CLC (formerly called a nursing home care unit) provides compassionate, person-centered care in a safe and 

homelike environment to eligible veterans who require a nursing home level of care. 
Combined Assessment Program Review of the VA Illiana Health Care System, Danville, Illinois 

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 administration 

and QM.

• Provide fraud and integrity awareness training to increase 

employee understanding of the potential for program 

fraud and the requirement to refer suspected criminal 

activity to the OIG.

Scope. We reviewed selected clinical and administrative 

activities to evaluate the effectiveness of patient care 

administration and QM. Patient care administration is the 

process of planning and delivering patient care. QM is the 

process of monitoring the quality of care to identify and 

correct harmful and potentially harmful practices and 

conditions. 

In performing the review, we inspected work areas; 

interviewed managers and employees; and reviewed clinical 

and administrative records. The review covered the 

following seven activities: 

• Coordination of Care.

• Emergency/Urgent Care Operations.

• EOC.

• Medication Management.

• QM Program.

• SHEP.

• Suicide Prevention Program.

The review covered system operations for FY 2008 and 

FY 2009 through March 13, 2009, and was done in 

accordance with OIG standard operating procedures for CAP 

reviews. We also followed up on health care 

recommendations from our prior CAP review of the system 

(Combined Assessment Program Review of the VA 

Illiana Health Care System, Danville, Illinois, Report 

No. 05-03220-108, March 22, 2006). We had one repeat 

EOC finding from our prior CAP review. 

VA Office of Inspector General 2 
Combined Assessment Program Review of the VA Illiana Health Care System, Danville, Illinois 

During this review, we also presented fraud and integrity 

awareness briefings for 403 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. Activities in the “Review Activities Without 

Recommendations” section have no reportable findings.

Organizational Strength 

National Center for 

Patient Safety 

Recognition

In 2008, VA’s NCPS initiated a formal recognition program to 

enhance the root cause analysis (RCA) process and 

recognize facility-level patient safety efforts. The 

Cornerstone program measures each VA facility against 

standard criteria and assesses the volume of RCAs 

conducted, the timeliness of completion, and the number of 

strong and intermediate actions developed from the RCAs. 

During FY 2008, the system conducted 25 RCAs. All 

25 were completed within the established 45-day timeframe. 

The system implemented a core RCA “Lead” group, an RCA 

Timeline Tracking Tool, and a Leadership RCA Review Tool. 

For these efforts, the system was recognized nationally as 

one of the four VA medical facilities that received the “gold,” 

which is the highest level of recognition in the Cornerstone 

program.

Results 

Review Activities With Recommendations 

Quality 

Management 

Program 

The purpose of this review was to evaluate whether the 

system had a comprehensive and effective QM program 

designed to monitor patient care activities and coordinate 

improvement efforts and whether senior managers actively 

supported the program’s activities. We interviewed the 

Director, the Chief of Staff, the Acting Chief of Quality 

Management, and key staff. We evaluated policies, 

performance improvement (PI) data, and other documents. 

The QM program was generally effective in providing 

oversight of the system’s quality of care, and senior 

managers supported the program through evaluation of PI 

VA Office of Inspector General 3 
Combined Assessment Program Review of the VA Illiana Health Care System, Danville, Illinois 

VA Office of Inspector General 4 

initiatives and through allocation of resources to the 

program. Appropriate review structures were in place for 

12 of the 14 program activities reviewed. We identified two 

areas that needed improvement. 

Credentialing and Privileging. VHA policy2 requires that 

clinical privileges be granted for a period not to exceed 

2 years and that privileges granted to contractors do not 

extend beyond the contract period. We reviewed the 

credentialing and privileging folders and corresponding 

contracts of seven contractors who had been initially 

privileged or reprivileged during the past 12 months. We 

found that five contractors had been granted clinical 

privileges that extended beyond the contract period. 

CPR and ACLS Training. VHA policy3 requires each 

medical facility to have a local policy governing CPR and 

ACLS training and a mechanism for monitoring the 

maintenance of this training.4 The system had a policy 

addressing the requirements for CPR and ACLS training and 

a plan for monitoring compliance with the policy. We found 

that the mechanism for tracking CPR training had only been 

partially implemented, which resulted in an incomplete 

database. We reviewed the database and found that 61 

employees who were required to maintain CPR certification 

were delinquent at the time of our visit. Because the 

mechanism was not being used to monitor ACLS training, we 

were unable to determine the status of ACLS certification for 

employees required to maintain it. 

 

Recommendation 1 We recommended that the VISN Director ensure that the 

System Director requires that clinical privileges granted to 

contractors do not extend beyond the contract period. 

The VISN and System Directors concurred with our finding 

and recommendation. The Professional Standards Board 

met and privilege end dates were changed to meet contract 

date requirements. The improvement plan is acceptable, 

and we will follow up to ensure implementation.

2

 VHA Handbook 1100.19, Credentialing and Privileging, October 2, 2007. 3

 VHA Directive 2008-008, Cardiopulmonary Resuscitation (CPR) and Advanced Cardiac Life Support (ACLS) 

Training for Staff, February 6, 2008. 4

 After the completion of initial CPR and ACLS training, employees are required to complete review training every 

2 years. 
Combined Assessment Program Review of the VA Illiana Health Care System, Danville, Illinois 

Recommendation 2 We recommended that the VISN Director ensure that the 

System Director requires that managers fully implement the 

mechanism established to track CPR and ACLS training 

compliance and that employees complete the training in 

accordance with system policy. 

The VISN and System Directors concurred with our findings 

and recommendation. The Education Service will set up a 

Basic Life Support and ACLS class in the Learning 

Management System, and employees who need to complete 

training will be assigned to the class. The Education Service 

will report on employee certification status monthly. The 

improvement plans are acceptable, and we will follow up on 

the planned actions until they are completed. 

Environment of 

Care 

The purpose of this review was to determine whether the 

system complied with selected IC standards and maintained 

a safe and clean patient care environment. VHA facilities 

are required to establish a comprehensive EOC program that 

fully meets VA NCPS, Occupational Safety and Health 

Administration, and Joint Commission (JC) standards. 

We inspected the medical, medical/surgical, and locked MH 

units and one CLC unit. We also followed up on EOC 

findings from our prior CAP review. Additionally, we asked 

for randomly selected preventive maintenance (PM) records 

for five defibrillators, one ventilator, and one 

electrocardiogram monitor to determine if PM was 

accomplished timely. All of these equipment items received 

PM at the required intervals. We identified the following 

areas that needed improvement. 

Cleaning in Patient Care Areas. We identified the need for 

greater attention to detail in the cleaning of patient rooms 

and restrooms, especially along baseboards and in floor 

corners. Also, managers need to ensure routine cleaning of 

medication and storage rooms as we noted debris 

accumulation on floors. 

Pest Control. We observed an active pest problem in the 

dining room of one patient care unit. Managers were 

uncertain if any actions had been initiated to address the 

problem. Additionally, we observed dead insects in light 

banks, between windows, and in patient care areas. Timely 

actions are necessary when active pest problems are 

VA Office of Inspector General 5 
Combined Assessment Program Review of the VA Illiana Health Care System, Danville, Illinois 

identified to ensure proper cleaning and the removal of dead 

insects. 

IC. We observed that emergency call system cords—usually 

located near commodes, sinks, and in shower areas—were 

made of rope and could not be easily cleaned or disinfected. 

These cords need to be replaced with a more suitable 

material, such as plastic. We found furniture, mattresses, 

and other patient care equipment items with compromised 

surfaces. Items such as these need to be regularly 

inspected, and those with compromised surfaces need to be 

repaired or removed from service. Also, we observed dust 

accumulation on air ventilation system covers and on internal 

ducts. This was a repeat finding from our prior CAP review. 

A routine cleaning schedule of the air ventilation system 

covers and ducting needs to be established to minimize the 

potential for the spread of infections. 

Patient Safety. We observed damaged laminate counter 

surfaces in patient restrooms, broken cabinetry, and 

damaged ceramic tiles. Employees need to identify and 

initiate work orders for the repair of items that may cause 

patient injury. We determined that managers had not 

ensured that required crash cart and defibrillator checks and 

medication and nourishment refrigerator temperature 

monitoring were accomplished in accordance with local 

policy. Also, we observed unsecured cleaning products and 

other patient care items, such as hydrogen peroxide, sodium 

chloride, and betadine. These items need to be secured to 

prevent accidental or purposeful ingestion. Additionally, we 

observed that multi-use vials of medications were not always 

dated when first used. As a result, staff might not recognize 

when the medications expire. 

EOC Rounds. We reviewed findings from the system’s most 

recent EOC rounds inspection of one patient care area and 

compared the findings with those from our inspection of the 

area. We identified a number of deficiencies that were not 

included in the system’s findings; however, some of these 

deficiencies had existed for several months. Managers need 

to ensure that members of the EOC rounds team are 

properly trained to identify cleanliness, pest control, IC, and 

patient safety issues. 

VA Office of Inspector General 6 
Combined Assessment Program Review of the VA Illiana Health Care System, Danville, Illinois 

Recommendation 3 We recommended that the VISN Director ensure that the 

System Director takes action to correct identified cleanliness, 

pest control, IC, and patient safety issues. 

The VISN and System Directors concurred with our findings 

and recommendation. A schedule for cleaning patient care 

areas has been established, and the pest control program 

has been enhanced. All pull cords have been replaced with 

cords that can be cleaned and disinfected. Nursing Service 

is conducting daily environmental rounds to monitor patient 

safety issues. The improvement plans are acceptable, and 

we will follow up on the planned actions until they are 

completed. 

Recommendation 4 We recommended that the VISN Director ensure that the 

System Director establishes effective processes to ensure 

that EOC deficiencies are identified and resolved. 

The VISN and System Directors concurred with our findings 

and recommendation. A training session on identifying 

cleanliness, pest control, IC, and patient safety issues will be 

held for service chiefs, supervisors, and all employees who 

participate in EOC rounds. A workgroup has been tasked to 

establish a mechanism to report the status of delinquent 

work orders. The improvement plans are acceptable, and 

we will follow up on the planned actions until they are 

completed. 

Coordination of 

Care 

The purpose of this review was to evaluate whether 

consultations, intra-facility transfers, and discharges were 

coordinated appropriately over the continuum of care and 

met VHA and JC requirements. Coordinated consultations, 

transfers, and discharges are essential to optimal patient 

outcomes. 

We determined that clinicians appropriately managed all 

12 intra-facility transfers reviewed. We found appropriate 

hand-off communication between providers and between 

nursing staff. Sending and receiving unit documentation was 

completed timely and in accordance with system policy. We 

identified two areas that needed improvement. 

Consultations. We reviewed the medical records of 

12 inpatients who had consultations ordered and performed 

internally. Two (17 percent) of the 12 consultation requests 

did not receive responses within the timeframe specified by 

system policy. Also, system policy requires that when a 

VA Office of Inspector General 7 
Combined Assessment Program Review of the VA Illiana Health Care System, Danville, Illinois 

VA Office of Inspector General 8 

STAT5 consultation is requested, the provider must contact 

the consulted department to discuss the patient’s needs. 

There was no evidence of communication between the 

provider and the consulted department for the one STAT 

consultation in our sample. 

Discharges. We reviewed the medical records of 

12 discharged patients. We found that 3 (25 percent) of the 

records contained inconsistencies between active outpatient 

medications listed in the provider’s discharge summary, 

those listed in the discharge instructions, and/or those listed 

in the medication reconciliation note. 

Recommendation 5 We recommended that the VISN Director ensure that the 

System Director takes action to ensure that consultation 

responses are received within the timeframe specified by 

system policy. 

The VISN and System Directors concurred with our findings 

and recommendation. The Chief of Staff has established a 

workgroup to review and revise system policy. Staff will be 

educated regarding the policy revision. The improvement 

plans are acceptable, and we will follow up on the planned 

actions until they are completed. 

Recommendation 6 We recommended that the VISN Director ensure that the 

System Director requires that active outpatient medications 

are correctly listed in all discharge documentation. 

The VISN and System Directors concurred with our findings 

and recommendation. The Patient Safety Committee (PSC) 

will develop a medication reconciliation tool. Each service 

will conduct monitoring. Results will be assessed by the 

PSC. The improvement plans are acceptable, and we will 

follow up on the planned actions until they are completed. 

Emergency/Urgent 

Care Operations 

The purpose of this review was to evaluate whether the 

system’s ER complied with VHA guidelines related to hours 

of operation, clinical capability, staffing adequacy, and 

nursing staff competency. In addition, we inspected the ER 

environment for cleanliness and safety. 

The ER is located in Building 98 and is open 24 hours per 

day, 7 days per week, as required for ER designation. The 

emergency services provided are within the system’s patient 

 

5

 Derived from the Latin word “statim,” which means immediately. 
Combined Assessment Program Review of the VA Illiana Health Care System, Danville, Illinois 

VA Office of Inspector General 9 

care capabilities. In addition, the system has a procedure in 

place for the management of patients whose care may 

exceed the system’s capability. 

We toured the ER and found the environment to be safe for 

the delivery of patient care. We determined that nurse 

staffing plans met local requirements and that nursing 

competencies were appropriately documented. We 

examined three medical equipment items and found that PM 

was completed, as required. We reviewed the medical 

records of five patients who presented to the ER with acute 

MH conditions and found that all five patients were managed 

appropriately. We identified two conditions that needed 

improvement. 

ER Physician Coverage. The ER utilizes 1 full-time 

physician for regular tours of duty and 18 contracted 

physicians for off-tour, weekend, and holiday coverage. We 

found that physicians left the ER without coverage when they 

were requested to pronounce a patient’s death in the 

inpatient and CLC units. We reviewed the medical records 

of three deceased patients and found that their deaths were 

pronounced by ER physicians. VHA policy6 requires that ER 

physicians have no responsibilities outside of the ER. 

Inter-Facility Transfers. We reviewed the medical records of 

two patients who were transferred out of the ER to local 

private hospitals and found that they did not contain one or 

more of the following: (a) documented evidence of date and 

time of the transfer, (b) an informed consent, (c) designation 

of the level of care required during transportation, or 

(d) documentation of the patient’s advanced directive status 

prior to transfer. VHA7

 and system policy require completion 

of an inter-facility transfer form, which is to be sent to the 

receiving facility at the time of transfer. ER staff confirmed 

that they were not using the mandated “VISN 11 Medical 

Center Inter-Facility Transfer Form.” 

Recommendation 7 We recommended that the VISN Director ensure that the 

System Director requires that ER physicians do not have 

responsibilities outside of the ER, in accordance with VHA 

policy. 

 6

 Deputy Under Secretary for Health for Operations and Management, “Clarification of Provider Staffing 

Requirements for Emergency Departments and Urgent Care Clinics in VHA,” memorandum, April 18, 2008. 

7

 VHA Directive 2007-015, Inter-Facility Transfer Policy, May 7, 2007. 
Combined Assessment Program Review of the VA Illiana Health Care System, Danville, Illinois 

VA Office of Inspector General 10 

The VISN and System Directors concurred with our findings 

and recommendation. The system has developed a contract 

statement of work for hospitalist coverage for evenings, 

weekends, and holidays. Once contract staff are on board, 

ER physicians will no longer have responsibilities outside of 

the ER. The improvement plans are acceptable, and we will 

follow up on the planned actions until they are completed. 

Recommendation 8 We recommended that the VISN Director ensure that the 

System Director requires that all inter-facility transfer 

documentation is in compliance with VHA and system policy. 

The VISN and System Directors concurred with our findings 

and recommendation. The system is now using forms that 

meet VHA requirements. The improvement plan is 

acceptable, and we will follow up to ensure implementation. 

Suicide Prevention 

Program 

The purpose of this review was to determine whether VHA 

health care facilities had implemented a suicide prevention 

program that was in compliance with VHA regulations. We 

assessed whether senior managers had appointed Suicide 

Prevention Coordinators (SPCs) at facilities and very large 

CBOCs,8 and we evaluated whether SPCs fulfilled all 

required functions. Also, we verified whether medical 

records of patients determined to be at high risk for suicide 

contained Category II Patient Record Flags (PRFs),9

documented safety plans that addressed suicidality, and 

documented collaboration between MH providers and SPCs. 

We interviewed the system’s SPC, and we reviewed 

pertinent policies and the medical records of five system 

patients and five CBOC patients determined to be at risk for 

suicide. We found that the suicide prevention program was 

generally effective. However, we identified the following 

area that needed improvement. 

Medical Record Review. We reviewed 10 medical records 

and found that all had the required PRFs. However, 

2 (20 percent) of the 10 records did not contain evidence of 

safety plans, and 1 of these 2 records did not have evidence 

of a 90-day review for continued placement, as required by 

system policy. Additionally, we identified that 1 (10 percent) 

of the 10 records had a current PRF and a safety plan but 

did not have documented evidence of collaboration between 

 

8

 Very large CBOCs are defined as clinics with more than 10,000 unique patients enrolled. 

9

 A Category II PRF is an alert mechanism that is displayed prominently in medical records. 
Combined Assessment Program Review of the VA Illiana Health Care System, Danville, Illinois 

VA Office of Inspector General 11 

the SPC and MH providers. VHA regulations10 require that 

all medical records of patients at high risk for suicide have a 

Category II PRF and a safety plan and show evidence of 

collaboration. 

Recommendation 9 We recommended that the VISN Director ensure that the 

System Director requires that medical record documentation 

for patients deemed at high risk for suicide is in compliance 

with VHA regulations and system policy. 

The VISN and System Directors concurred with our findings 

and recommendation. The SPC and the case manager will 

monitor high-risk patients daily to ensure that they have 

PRFs and completed safety plans. Also, the SPC and the 

case manager will assure ongoing, interdisciplinary 

collaboration. The improvement plans are acceptable, and 

we will follow up on the planned actions until they are 

completed. 

Review Activities Without Recommendations 

Medication 

Management 

The purpose of this review was to evaluate whether the 

system had adequate medication management practices. A 

safe medication management system includes medication 

ordering, administering, and monitoring. 

We reviewed selected medication management processes in 

the locked MH, intensive care, and medical/surgical units 

and in two CLC units. We found adequate management of 

medications brought into the system by patients or their 

families. Nurses appropriately scanned patient armbands 

and used personal identifiers to correctly identify patients 

prior to medication administration. Also, we found that 

reconciliation of controlled substances discrepancies at the 

unit level was adequate. 

We reviewed 44 randomly selected doses of PRN (as 

needed) pain medication to determine if clinicians 

documented effectiveness within 4 hours of administration, 

as required by system policy. Clinicians met this 

requirement in 41 (93 percent) of the doses. We made no 

recommendations. 

 

 VHA Handbook 1160.01, Uniform Mental Health Services in VA Medical Centers and Clinics, 

September 11, 2008. 
Combined Assessment Program Review of the VA Illiana Health Care System, Danville, Illinois 

Survey of 

Healthcare 

Experiences of 

Patients 

The purpose of this review was to assess the extent that the 

system used quarterly SHEP results to improve patient care, 

treatment, and services. The Performance Analysis Center 

for Excellence of the Office of Quality and Performance 

within VHA is the analytical, methodological, and reporting 

staff for SHEP. VHA set performance measure results for 

patients reporting overall satisfaction of “very good” or 

“excellent” at 76 percent for inpatients and 77 percent for 

outpatients. 

Figures 1 and 2 (below and on the next page) show the 

system’s SHEP performance measure results for inpatients 

and outpatients, respectively. 

60

65

70

75

80

85

90

95

100

Qtr 1 (FY 07) Qtr 2 (FY 07) Qtr 3 (FY 07) Qtr 4 (FY 07) Qtr 1 (FY 08) Qtr 2 (FY 08) Qtr 3 (FY 08) Qtr 4 (FY 08)

Percent Reporting Overall Quality as Very Good or Excellent

Quarter Reported

Facility

VISN

National

VA ILLIANA HEALTH CARE SYSTEM

INPATIENT OVERALL QUALITY

BY QUARTER

Meets 

Target

Figure 1:

VA Office of Inspector General 12 
Combined Assessment Program Review of the VA Illiana Health Care System, Danville, Illinois 

60

65

70

75

80

85

90

95

100

Qtr 1 (FY 07) Qtr 2 (FY 07) Qtr 3 (FY 07) Qtr 4 (FY 07) Qtr 1 (FY 08) Qtr 2 (FY 08) Qtr 3 (FY 08) Qtr 4 (FY 08)

Percent Reporting Overall Quality as Very Good or Excellent

Quarter Reported

Facility

VISN

National

VA ILLIANA HEALTH CARE SYSTEM

OUTPATIENT OVERALL QUALITY

BY QUARTER

Figure 2:

Meets 

Target

We reviewed survey results for FYs 2007 and 2008. The 

system’s inpatient results exceeded the target in 3 of the 

8 quarters reviewed. The system’s outpatient results 

exceeded the target in 6 of the 8 quarters reviewed. 

Managers had analyzed survey results, identified 

opportunities for improvement, initiated an action plan, and 

evaluated the plan for effectiveness. Therefore, we made no 

recommendations. 

VA Office of Inspector General 13 
Combined Assessment Program Review of the VA Illiana Health Care System, Danville, Illinois 

Appendix A 

VISN Director Comments 

VA Office of Inspector General 14 

Department of 

Veterans Affairs Memorandum 

Date: May 22, 2009 

From: Director, Veterans In Partnership Network (10N11) 

Subject: Combined Assessment Program Review of the VA Illiana 

Health Care System, Danville, Illinois 

To: Director, Chicago and Kansas City Offices of Healthcare 

Inspections (54CH/KC) 

Director, Management Review Service (10B5) 

Per your request, attached is the response to the draft report from VA 

Illiana HCS. 

If you have any questions, please contact Jim Rice, VISN 11 QMO, at 

(734) 222-4314. 

MICHAEL S. FINEGAN 

Attachment 
Combined Assessment Program Review of the VA Illiana Health Care System, Danville, Illinois 

Appendix B 

System Director Comments 

VA Office of Inspector General 15 

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 the VISN Director ensure 

that the System Director requires that clinical privileges granted to 

contractors do not extend beyond the contract period. 

Concur Target Date of Completion: April 2, 2009

Plan of action: The Professional Standards Board met and privilege end 

dates were changed to meet contract date requirements. 

Recommendation 2. We recommended that the VISN Director ensure 

that the System Director requires that managers fully implement the 

mechanism established to track CPR and ACLS training compliance and 

that employees complete the training in accordance with system policy. 

Concur Target Date of Completion: July 1, 2009 

Plan of action: The Education Service will set up a class in LMS of 

everyone that needs to complete BLS and ACLS and an assignment will 

be made utilizing assignment profile. Reports can than be run against the 

LMS item for BLS and ACLS showing employees certification status, 

including deficiencies and upcoming renewals. The Education Service will 

run this report and send to service chiefs and report through the Education 

and Training Committee monthly. 

Recommendation 3. We recommended that the VISN Director ensure 

that the System Director takes action to correct identified cleanliness, pest 

control, IC, and patient safety issues. 

Concur Target Date of Completion: Listed below. 

Plan of action: 

• Cleaning Patient Care Areas: A schedule has been established 

for the Chief of EMS and supervisors to make weekly rounds 

utilizing a checklist in the patient care areas. The cleaning 

schedule for all units includes weekly and as needed cleaning of 

medication and storage rooms. (Completed: April 24, 2009)
Combined Assessment Program Review of the VA Illiana Health Care System, Danville, Illinois 

• Pest Control: The pest control program has been enhanced to 

increase frequency and surveillance. Part of the weekly rounds 

being conducted by EMS includes quality control of pest control 

contract and making enhancements. (Completed: April 1, 2009) 

• Infection Control: All pull cords have been replaced by cords that 

can be cleaned and disinfected after use (Completed: 

April 13, 2009). EOC rounds include inspection of furniture, 

equipment, etc., along with staff education to identify deficiencies 

more timely. (Completed: May 1, 2009) 

• Patient Safety: Nurse Managers met with staff regarding 

importance of completion of monitors for crash cart/defibrillator and 

refrigerator temperature. On going surveillance of these monitors, 

along with unsecured cleaning products and medications are part of 

regular environmental rounds conducted by Nursing Service daily 

and will be reemphasized with staff during rounds. (Completed: 

April 30, 2009) 

Recommendation 4. We recommended that the VISN Director ensure 

that the System Director establishes effective processes to ensure that 

EOC deficiencies are identified and resolved. 

Concur Target Date of Completion: August 1, 2009 

Plan of action: 

• A training session to identify cleanliness, pest control, IC, and 

patient safety issues will be held for all employees who participate 

in the facility EOC rounds, service chiefs, and supervisors. 

• EOC checklist and deficiency list are sent to the area of inspection 

two weeks prior so staff can perform EOC rounds proactively. 

• A workgroup has been established to identify and develop an 

administrative system redesign to establish a mechanism to report 

status of work orders greater than 30 days for evaluation and 

improve timeliness of completion. 

Recommendation 5. We recommended that the VISN Director ensure 

that the System Director takes action to ensure that consultation 

responses are received within the timeframe specified by system policy. 

Concur Target Date of Completion: July 1, 2009 

Plan of action: The Chief of Staff has established a workgroup to review 

and revise the MCM to address the OIG findings. Staff education will be 

provided in conjunction with finalization of the policy revision. 

VA Office of Inspector General 16 
Combined Assessment Program Review of the VA Illiana Health Care System, Danville, Illinois 

Recommendation 6. We recommended that the VISN Director ensure 

that the System Director requires that active outpatient medications are 

correctly listed in all discharge documentation. 

Concur Target Date of Completion: January 1, 2010 

Plan of action: 

• The PSC will evaluate development of a medication reconciliation 

tool to be shared with staff. (Completion: September 1, 2009)

• Each service will monitor and review at least 10 records per 

provider (if less than 10 then 100% of records) each month to 

check for consistency/accuracy for a period of one quarter. 

(Completion: September 1, 2009 to November 30, 2009)

• Results will be assessed by PSC for further compliance analysis. 

(Completion: December 12, 2009)

• Add this monitor to service chiefs ECF performance plans and will 

be updated with this monitor in their mission critical element.

Recommendation 7. We recommended that the VISN Director ensure 

that the System Director requires that ER physicians do not have 

responsibilities outside of the ER, in accordance with VHA policy. 

Concur Target Date of Completion: December 15, 2009 

Plan of action: In order to address compliance with VHA policy, VA 

Illiana Health Care System has developed a contract statement of work for 

Hospitalist coverage for evenings, weekends, and holidays. Once the 

contract has been announced and contract staff on board, Emergency 

Department physicians will not have responsibilities outside of the 

Emergency Department. 

Recommendation 8. We recommended that the VISN Director ensure 

that the System Director requires that all inter-facility transfer 

documentation is in compliance with VHA and system policy. 

Concur Target Date of Completion: May 2009 

Plan of action: The use of the forms meeting the requirements as set 

forth in VHA Directive 2007-015 was implemented shortly before the OIG 

visit and is fully implemented at this time. 

Recommendation 9. We recommended that the VISN Director ensure 

that the System Director requires that medical record documentation for 

VA Office of Inspector General 17 
Combined Assessment Program Review of the VA Illiana Health Care System, Danville, Illinois 

VA Office of Inspector General 18 

patients deemed at high risk for suicide is in compliance with VHA 

regulations and system policy. 

Concur Target Date of Completion: May 7, 2009 

Plan of action: The SPC and new Case Manager provide additional daily 

monitoring of veterans at high risk for suicidal behavior to ensure they 

have a patient record flag and a completed safety plan with subsequent 

reviews and timely follow-up. Interdisciplinary collaboration and 

consensus regarding high risk cases is ensured through SPC and case 

manager attendance at inpatient treatment team meetings. SPC and case 

manager assure ongoing interdisciplinary collaboration and 

communication with outpatient providers through telephone consultation(s) 

and adding the providers as additional signers of their progress notes. 
Combined Assessment Program Review of the VA Illiana Health Care System, Danville, Illinois 

Appendix C 

VA Office of Inspector General 19 

OIG Contact and Staff Acknowledgments 

Contact Verena Briley-Hudson, MN, RN 

Director, Chicago and Kansas City Offices of Healthcare 

Inspections 

(708) 202-2672 

Contributors Paula Chapman, CTRS, Team Leader 

Judy Brown 

Tishanna McCutchen, MSPH, MSN, RN 

Jennifer Reed, RN 

Roberta Thompson, MSW 

John Brooks, Office of Investigations 
Combined Assessment Program Review of the VA Illiana Health Care System, Danville, Illinois 

Appendix D 

VA Office of Inspector General 20 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, Veterans In Partnership Network (10N11) 

Director, VA Illiana Health Care System (550/00) 

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: Evan Bayh, Roland W. Burris, Richard Durbin, Richard G. Lugar 

U.S. House of Representatives: Steve Buyer, Brad Ellsworth, 

Deborah “Debbie” Halvorson, Phil Hare, Timothy V. Johnson, Aaron Schock, 

John Shimkus, Peter Visclosky 

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