Department of Veterans Affairs 

Office of Inspector General 

Office of Healthcare Inspections
 

Report No. 11-03665-78 

Combined Assessment Program
 

Review of the
 

VA Illiana Health Care System
 

Danville, Illinois
 

February 14, 2012
 

Washington, DC 20420
 
Why We Did This Review 

Combined Assessment Program (CAP) reviews are part of the Office of Inspector 

General's (OIG's) efforts to ensure that high quality health care is provided to our 

Nation's veterans. CAP reviews combine the knowledge and skills of the OIG's Offices 

of Healthcare Inspections and Investigations to provide collaborative assessments of 

VA medical facilities on a cyclical basis. The purposes of CAP reviews are to: 

 Evaluate how well VA facilities are accomplishing their missions of providing veterans 

convenient access to high quality medical services. 

 Provide crime awareness briefings to increase employee understanding of the 

potential for program fraud and the requirement to refer suspected criminal activity to 

the OIG. 

In addition to this typical coverage, CAP reviews may examine issues or allegations 

referred by VA employees, patients, Members of Congress, or others. 

To Report Suspected Wrongdoing in VA Programs and Operations 

Telephone: 1-800-488-8244 

E-Mail: vaoighotline@va.gov 

(Hotline Information: http://www.va.gov/oig/contacts/hotline.asp) 
CAP Review of the VA Illiana Health Care System, Danville, IL 

Glossary 

CAP Combined Assessment Program 

CLC community living center 

CRC colorectal cancer 

ED emergency department 

EOC environment of care 

facility VA Illiana Health Care System 

FY fiscal year 

HF heart failure 

MCM medical center memorandum 

MH mental health 

MSDS Material Safety Data Sheet 

OIG Office of Inspector General 

OR operating room 

QM quality management 

VHA Veterans Health Administration 

VISN Veterans Integrated Service Network 

VA OIG Office of Healthcare Inspections 
CAP Review of the VA Illiana Health Care System, Danville, IL 

Table of Contents
 

Page
 

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

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

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

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

Reported Accomplishments...................................................................................... 2
 

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

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

EOC................................................................................................................... 3
 

Polytrauma ........................................................................................................ 5
 

Medication Management ................................................................................... 7
 

Review Activities Without Recommendations ......................................................... 8
 

CRC Screening.................................................................................................. 8
 

Coordination of Care ......................................................................................... 8
 

Moderate Sedation ............................................................................................ 9
 

QM..................................................................................................................... 10
 

Comments................................................................................................................... 12
 

Appendixes 

A. Facility Profile .................................................................................................... 13
 

B. Follow-Up on Previous Recommendations........................................................ 14
 

C. VHA Satisfaction Surveys and Hospital Outcome of Care Measures................ 16
 

D. VISN Director Comments .................................................................................. 18
 

E. Acting Facility Director Comments..................................................................... 19
 

F. OIG Contact and Staff Acknowledgments ......................................................... 23
 

G. Report Distribution ............................................................................................ 24
 

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

Review of the VA Illiana Health Care System, Danville, IL 

Review Purpose: The purpose was 

to evaluate selected activities, focusing 

on patient care administration and 

quality management, and to provide 

crime awareness training. We 

conducted the review the week of 

November 14, 2011. 

Review Results: The review covered 

seven activities. We made no 

recommendations in the following 

activities: 

 Colorectal Cancer Screening 

 Coordination of Care 

 Moderate Sedation 

 Quality Management 

The facility’s reported accomplishments 

were the implementation of The Green 

House® model as a new and innovative 

approach for veterans needing skilled 

care and the construction of a Healing 

Garden for community living center 

residents, which incorporates access to 

nature in a therapeutic setting. 

Recommendations: We made 

recommendations in the following three 

activities: 

Environment of Care: Ensure that fire 

exits are identified by visible signage, 

are not locked, and are clear of 

obstructions and not blocked. Clean 

operating room ceiling lights, and repair 

the walls in the operating room. 

Develop and implement a policy for the 

community living center’s residential 

animal program, and ensure that 

quarterly preventive maintenance is 

performed on the community living 

center’s elopement prevention system. 

Review and update Material Safety Data 

Sheet files annually. 

Polytrauma: Ensure interdisciplinary 

teams develop care plans that contain 

all required elements. Require 

monitoring of compliance with staff 

training requirements. 

Medication Management: Ensure that 

clinicians document all required 

vaccination administration elements and 

that compliance is monitored. 

Comments 

The Veterans Integrated Service 

Network and Acting Facility Directors 

agreed with the Combined Assessment 

Program review findings and 

recommendations and provided 

acceptable improvement plans. We will 

follow up on the planned actions until 

they are completed. 

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

Assistant Inspector General for
 

Healthcare Inspections
 

VA OIG Office of Healthcare Inspections i 
CAP Review of the VA Illiana Health Care System, Danville, IL 

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 crime awareness briefings to increase employee understanding of the 

potential for program fraud and the requirement to refer suspected criminal 

activity to the OIG. 

Scope 

We reviewed selected clinical and administrative activities to evaluate the effectiveness 

of patient care administration and QM. Patient care administration is the process of 

planning and delivering patient care. QM is the process of monitoring the quality of care 

to identify and correct harmful and potentially harmful practices and conditions. 

In performing the review, we inspected selected areas, interviewed managers and 

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

following seven activities: 

	 CRC Screening 

	 Coordination of Care 

	 EOC 

	 Medication Management 

	 Moderate Sedation 

	 Polytrauma 

	 QM 

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

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

size, function, or frequency of occurrence. 

The review covered facility operations for FY 2011 and FY 2012 through 

November 17, 2011, and was done in accordance with OIG standard operating 

procedures for CAP reviews. We also followed up on selected recommendations from 

our prior CAP review of the facility (Combined Assessment Program Review of the VA 

VA OIG Office of Healthcare Inspections 1 
CAP Review of the VA Illiana Health Care System, Danville, IL 

Illiana Health Care System, Danville, Illinois, Report No. 08-02602-140, June 3, 2009). 

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

During this review, we also presented crime awareness briefings for 101 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 

258 responded. Survey results were shared 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. 

Reported Accomplishments
 

The Green House® Model 

The facility recently dedicated two homes developed on the Green House® model, 

which will provide a new and innovative approach for veterans who need to live in a 

skilled care setting. The facility is the first in the VA system to implement this model. 

The Green House® model allows individuals to live in a group home designed, 

equipped, and staffed to deliver personal care and clinical services. Each home will 

house 10 veterans, who will have their own private bedroom and bathroom. The private 

rooms are situated around a hearth area with an open kitchen and dining room. Staff 

will prepare home cooked meals in the kitchen and serve them at a large, single dining 

table. 

Healing Garden 

The facility built a “Healing Garden” for CLC residents, which incorporates access to 

nature in a therapeutic setting. It is an ongoing initiative to provide a physical 

environment that can enhance healing, health, and well-being. Features include a 

picnic pavilion, gazebo, benches, recreational game areas, and items such as 

birdfeeders. A colored concrete path loops continuously throughout the entire garden 

and is accessible to wheelchairs. 

VA OIG Office of Healthcare Inspections 2 
CAP Review of the VA Illiana Health Care System, Danville, IL 

Results 

Review Activities With Recommendations 

EOC 

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

clean health care environment in accordance with applicable requirements. 

We inspected inpatient units (medical/surgical, MH, and CLC), the ED, the OR, and 

outpatient clinics (dental, polytrauma, primary care, and specialty care). Additionally, 

we reviewed facility policies, meeting minutes, training records, and other relevant 

documents, and we interviewed employees and managers. The areas marked as 

noncompliant in the table below needed improvement. Details regarding the findings 

follow the table. 

Noncompliant Areas Reviewed for EOC 

Patient care areas were clean. 

X Fire safety requirements were properly addressed. 

Environmental safety requirements were met. 

X Infection prevention requirements were met. 

Medications were secured and properly stored, and medication safety 

practices were in place. 

Sensitive patient information was protected. 

X If the CLC had a resident animal program, facility policy addressed VHA 

requirements. 

Laser safety requirements in the OR were properly addressed, and users 

received medical laser safety training. 

X The facility complied with any additional elements required by local policy. 

Areas Reviewed for MH Residential Rehabilitation Treatment Program 

There was a policy that addressed safe medication management, 

contraband detection, and inspections. 

MH Residential Rehabilitation Treatment Program inspections were 

conducted, included all required elements, and were documented. 

Actions were initiated when deficiencies were identified in the residential 

environment. 

Access points had keyless entry and closed circuit television monitoring. 

Female veteran rooms and bathrooms in mixed gender units were 

equipped with keyless entry or door locks. 

The facility complied with any additional elements required by local policy. 

Fire Safety. The Joint Commission requires that fire exits are identified by visible 

signage, are not locked, and are clear of obstructions and not blocked. We found that 

exit signs in the OR had been removed and not replaced. Additionally, we found a 

locked exit door on the medical/surgical unit and a blocked exit in the CLC. 

VA OIG Office of Healthcare Inspections 3 
CAP Review of the VA Illiana Health Care System, Danville, IL 

Infection Prevention. The Joint Commission requires the facility to maintain a safe 

environment and reduce the risk of infections. In the OR, we found dead insects in the 

ceiling lights and gashes and holes in the walls. 

VHA requires that the facility develop and implement a local policy if they have a 

residential animal program.1 The CLC had a residential animal program; however, the 

facility had not developed and implemented a policy. 

Patient Safety. Local policy requires that preventive maintenance be performed 

quarterly on the elopement prevention system in the CLC. The required quarterly 

preventive maintenance was not performed. 

MSDS Files. Local policy requires that each service annually review and update their 

MSDS files. We found outdated MSDS files in seven of the nine clinical areas 

inspected. 

Recommendations 

1. We recommended that processes be strengthened to ensure that all fire exits are 

identified by visible signage, are not locked, and are clear of obstructions and not 

blocked. 

2. We recommended that processes in the OR be strengthened to ensure that ceiling 

lights are clean and that the walls are repaired and maintained. 

3. We recommended that a policy be developed and implemented for the CLC’s 

residential animal program. 

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

preventive maintenance is performed on the CLC’s elopement prevention system. 

5. We recommended that processes be strengthened to ensure that MSDS files are 

reviewed and updated annually. 

1 Under Secretary for Health, “Non-Research Animals in Health Care Facilities,” Information Letter 10-2009-007, 

June 11, 2009. 

VA OIG Office of Healthcare Inspections 4 
CAP Review of the VA Illiana Health Care System, Danville, IL 

Polytrauma 

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

requirements related to screening, evaluation, and coordination of care for patients 

affected by polytrauma. 

We reviewed relevant documents, 10 medical records of patients with positive traumatic 

brain injury results, and training records, and we interviewed key staff. The areas 

marked as noncompliant in the table below needed improvement. Details regarding the 

findings follow the table. 

Noncompliant Areas Reviewed 

Providers communicated the results of the traumatic brain injury screening 

to patients and referred patients for comprehensive evaluations within the 

required timeframe. 

Providers performed timely, comprehensive evaluations of patients with 

positive screenings. 

Case Managers were appropriately assigned to outpatients and provided 

frequent, timely communication. 

X Outpatients who needed interdisciplinary care had treatment plans 

developed that included all required elements. 

Adequate services and staffing were available for the polytrauma care 

program. 

X Employees involved in polytrauma care were properly trained. 

Case Managers provided frequent, timely communication with hospitalized 

polytrauma patients. 

The interdisciplinary team coordinated inpatient care planning and 

discharge planning. 

Patients and their family members received follow-up care instructions at 

the time of discharge from the inpatient unit. 

Polytrauma-Traumatic Brain Injury System of Care facilities provided an 

appropriate care environment. 

The facility complied with any additional elements required by local policy. 

Outpatient Case Management. VHA requires that a specific interdisciplinary treatment 

plan be developed.2 The plan developed by the interdisciplinary team must address 

specific elements, including the skills needed to maximize independence and the 

recommended type of vocational rehabilitation. In addition, the plan needs to address 

family education and the family support needed during the receipt of outpatient services. 

None of the 10 polytrauma outpatients’ interdisciplinary treatment plans contained all 

the required elements. 

2 VHA Handbook 1172.04, Physical Medicine and Rehabilitation Individualized Rehabilitation and Community 

Reintegration Care Plan, May 3, 2010. 

VA OIG Office of Healthcare Inspections 5 
CAP Review of the VA Illiana Health Care System, Danville, IL 

Training. VHA requires staff working with polytrauma patients to have training in 

age-appropriate interventions, assistive technology, and pain management.3 None of 

the 10 training records reviewed contained evidence of all required training. 

Recommendations 

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

teams develop care plans that contain all required elements. 

7. We recommended that the facility monitor compliance with polytrauma training 

requirements. 

3 VHA Handbook 1172.1, Polytrauma Rehabilitation Procedures, September 22, 2005. 

VA OIG Office of Healthcare Inspections 6 
CAP Review of the VA Illiana Health Care System, Danville, IL 

Medication Management 

The purpose of this review was to determine whether VHA facilities had properly 

provided selected vaccinations according to Centers for Disease Control and Prevention 

guidelines and VHA recommendations. 

We reviewed a total of 30 medical records for evidence of screening and administration 

of pneumococcal vaccines to CLC residents and screening and administration of 

tetanus and shingles vaccines to CLC residents and primary care patients. We also 

reviewed documentation of selected vaccine administration requirements and 

interviewed key personnel. 

The area marked as noncompliant in the table below needed improvement. Details 

regarding the finding follow the table. 

Noncompliant Areas Reviewed 

Staff screened patients for pneumococcal and tetanus vaccinations. 

Staff properly administered pneumococcal and tetanus vaccinations. 

X Staff properly documented vaccine administration. 

Vaccines were available for use. 

If applicable, staff provided vaccines as expected by the VISN. 

The facility complied with any additional elements required by local policy. 

Vaccination Documentation. Federal law requires that documentation for administered 

vaccinations include specific elements, such as the vaccine manufacturer and lot 

number of the vaccine used. Clinicians did not document all required elements in 

6 (20 percent) records. 

Recommendation 

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

document all required vaccination administration elements and that compliance is 

monitored. 

VA OIG Office of Healthcare Inspections 7 
CAP Review of the VA Illiana Health Care System, Danville, IL 

Review Activities Without Recommendations
 

CRC Screening 

The purpose of this review was to follow up on a report, Healthcare 

Inspection – Colorectal Cancer Detection and Management in Veterans Health 

Administration Facilities (Report No. 05-00784-76, February 2, 2006) and to assess the 

effectiveness of VHA’s CRC screening. 

We reviewed the medical records of 20 patients who had positive CRC screening tests, 

and we interviewed key employees involved in CRC management. The table below 

details the areas reviewed. The facility generally met requirements. We made no 

recommendations. 

Noncompliant Areas Reviewed 

Patients were notified of positive screening test results within the required 

timeframe. 

Clinicians responsible for initiating follow-up either developed plans or 

documented no follow-up was indicated within the required timeframe. 

Patients received a diagnostic test within the required timeframe. 

Patients were notified of the diagnostic test results within the required 

timeframe. 

Patients who had biopsies were notified within the required timeframe. 

Patients were seen in surgery clinic within the required timeframe. 

The facility complied with any additional elements required by local policy. 

Coordination of Care 

The purpose of this review was to determine whether patients with a primary discharge 

diagnosis of HF received adequate discharge planning and care “hand-off” and timely 

primary care or cardiology follow-up after discharge that included evaluation and 

documentation of HF management key components. 

We reviewed 24 HF patients’ medical records and relevant facility policies, and we 

interviewed employees. The table below details the areas reviewed. The facility 

generally met requirements. We made no recommendations. 

Noncompliant Areas Reviewed 

Medications in discharge instructions matched those ordered at discharge. 

Discharge instructions addressed medications, diet, and the initial follow-up 

appointment. 

Initial post-discharge follow-up appointments were scheduled within the 

providers’ recommended timeframes. 

The facility complied with any additional elements required by local policy. 

VA OIG Office of Healthcare Inspections 8 
CAP Review of the VA Illiana Health Care System, Danville, IL 

Moderate Sedation 

The purpose of this review was to determine whether the facility developed safe 

processes for the provision of moderate sedation that complied with applicable 

requirements. 

We reviewed relevant documents, three medical records, and training/competency 

records, and we interviewed key individuals. The table below details the areas 

reviewed. The facility generally met requirements. We made no recommendations. 

Noncompliant Areas Reviewed 

Staff completed competency-based education/training prior to assisting 

with or providing moderate sedation. 

Pre-sedation documentation was complete. 

Informed consent was completed appropriately and performed prior to 

administration of sedation. 

Timeouts were appropriately conducted. 

Monitoring during and after the procedure was appropriate. 

Moderate sedation patients were appropriately discharged. 

The use of reversal agents in moderate sedation was monitored. 

If there were unexpected events/complications from moderate sedation 

procedures, the numbers were reported to an organization-wide venue. 

If there were complications from moderate sedation, the data was analyzed 

and benchmarked, and actions taken to address identified problems were 

implemented and evaluated. 

The facility complied with any additional elements required by local policy. 

VA OIG Office of Healthcare Inspections 9 
CAP Review of the VA Illiana Health Care System, Danville, IL 

QM 

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

actively supported and appropriately responded to QM efforts and whether VHA 

facilities complied with selected requirements within their QM programs. 

We interviewed senior managers and QM personnel, and we evaluated meeting 

minutes, medical records, and other relevant documents. The table below details the 

areas reviewed. The facility generally met requirements. We made no 

recommendations. 

Noncompliant Areas Reviewed 

There was a senior-level committee/group responsible for QM/performance 

improvement, and it included all required members. 

There was evidence that inpatient evaluation data were discussed by 

senior managers. 

The protected peer review process complied with selected requirements. 

Licensed independent practitioners’ clinical privileges from other institutions 

were properly verified. 

Focused Professional Practice Evaluations for newly hired licensed 

independent providers complied with selected requirements. 

Staff who performed utilization management reviews met requirements and 

participated in daily interdisciplinary discussions. 

If cases were referred to a physician utilization management advisor for 

review, recommendations made were documented and followed. 

There was an integrated ethics policy, and an appropriate annual 

evaluation and staff survey were completed. 

If ethics consultations were initiated, they were completed and 

appropriately documented. 

There was a cardiopulmonary resuscitation review policy and process that 

complied with selected requirements. 

Data regarding resuscitation episodes were collected and analyzed, and 

actions taken to address identified problems were evaluated for 

effectiveness. 

If Medical Officers of the Day were responsible for responding to 

resuscitation codes during non-administrative hours, they had current 

Advanced Cardiac Life Support certification. 

There was a medical record quality review committee, and the review 

process complied with selected requirements. 

If the evaluation/management coding compliance report contained 

failures/negative trends, actions taken to address identified problems were 

evaluated for effectiveness. 

Copy and paste function monitoring complied with selected requirements. 

The patient safety reporting mechanisms and incident analysis complied 

with policy. 

There was evidence at the senior leadership level that QM, patient safety, 

and systems redesign were integrated. 

Overall, if significant issues were identified, actions were taken and 

evaluated for effectiveness. 

VA OIG Office of Healthcare Inspections 10 
CAP Review of the VA Illiana Health Care System, Danville, IL 

Noncompliant Areas Reviewed 

Overall, there was evidence that 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 complied with any additional elements required by local policy. 

VA OIG Office of Healthcare Inspections 11 
CAP Review of the VA Illiana Health Care System, Danville, IL 

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

recommendations and provided acceptable improvement plans. (See Appendixes D 

and E, pages 18–22 for full text of the Directors’ comments.) We consider 

Recommendations 1 and 2 closed. We will follow up on the planned actions for the 

open recommendations until they are completed. 

VA OIG Office of Healthcare Inspections 12 
CAP Review of the VA Illiana Health Care System, Danville, IL 

Appendix A 

Facility Profile4 

Type of Organization Acute medical, acute MH, CLC, and primary 

care 

Complexity Level Level 2 

VISN 11 

Community Based Outpatient Clinics Decatur, IL 

Mattoon, IL 

Peoria, IL 

Springfield, IL 

West Lafayette, IN 

Veteran Population in Catchment Area 136,009 

Type and Number of Total Operating Beds: 

 Hospital, including Psychosocial 

Residential Rehabilitation Treatment 

Program 

56 

 CLC/Nursing Home Care Unit 165 

 Other NA 

Medical School Affiliations University of Illinois College of Medicine, 

Urbana, IL, 

University of Illinois College of Medicine, 

Peoria, IL, 

 Number of Residents 12 

Resources (in millions): 

 Total Medical Care Budget 

Current FY (through 

October 2011) 

$217.5 

Prior FY (2011) 

$219.9 

 Medical Care Expenditures $14.3 $207.3 

Total Medical Care Full-Time Employee 

Equivalents 

Workload: 

 Number of Station Level Unique 

Patients 

 Inpatient Days of Care: 

o Acute Care 

1,386 

11,048 

868 

1,379 

33,335 

11,544 

o CLC/Nursing Home Care Unit 3,978 52,401 

Hospital Discharges 176 2,498 

Total Average Daily Census (including all bed 

types) 

161.00 180.51 

Cumulative Occupancy Rate (in percent) 63.38 71.06 

Outpatient Visits 18,362 324,540 

4 All data provided by facility management. 

VA OIG Office of Healthcare Inspections 13 
CAP Review of the VA Illiana Health Care System, Danville, IL 

Appendix B 

Follow-Up on Previous Recommendations 

Recommendations Current Status of Corrective Actions Taken Repeat 

Recommendation? 

Y/N 

QM 

1. Ensure that clinical privileges granted to 

contractors do not extend beyond the 

contract period. 

The Executive Committee of the Medical Staff reviews all 

contracted providers’ privileges to ensure privileges do 

not exceed contract length. A process was established 

that credentialing must have a copy of the contract for 

privileging. 

N 

2. Ensure that managers fully implement 

the mechanism established to track 

cardiopulmonary resuscitation and 

Advanced Cardiac Life Support training 

compliance and that employees complete 

the training in accordance with facility 

policy. 

The Basic Life Support and Advanced Cardiac Life 

Support report showing employees certification status, 

including deficiencies and upcoming renewals, is sent 

monthly to all service chiefs and supervisors. 

N 

EOC 

3. Ensure that cleanliness, pest control, 

infection control, and patient safety issues 

are corrected. 

A schedule was established for the Chief, Environmental 

Management Service and supervisors to make daily 

patient care area rounds. The rounds include pest 

control management. All medication refrigerators are 

now on an electronic system that is monitored 24 hours a 

day to ensure temperatures stay in range. All crash 

carts/defibrillators are monitored at the unit level. 

N 

4. Ensure that an effective process is 

established to identify and resolve EOC 

deficiencies. 

A training session to identify cleanliness, pest control, 

infection control, and patient safety is presented quarterly 

to employees who participate in EOC rounds. A 

mechanism was created to report work order status 

greater than 30 days for evaluation and to improve 

timeliness of completion. 

N 

VA OIG Office of Healthcare Inspections 14 
CAP Review of the VA Illiana Health Care System, Danville, IL 

Appendix B 

Recommendations Current Status of Corrective Actions Taken Repeat 

Recommendation? 

Y/N 

Coordination of Care 

5. Ensure that consultation responses are 

received within the timeframe specified by 

facility policy. 

All prior action items were completed. All consults are 

monitored at the service level for timeliness. Current 

backlogs with fee and prosthetic consults are monitored. 

N 

6. Ensure that active outpatient 

medications are correctly listed in all 

discharge documentation. 

Medication reconciliation is monitored. Data 

demonstrates continuous improvement. 

N 

Emergency/Urgent Care Operations 

7. Ensure that ED physicians do not have 

responsibilities outside the ED. 

The facility has full-time contract hospitalist coverage for 

acute care, MH, and the CLC. ED physicians no longer 

have responsibilities outside of the ED. 

N 

8. Ensure that all inter-facility transfer 

documentation is in compliance with VHA and 

facility policy. 

The use of the forms meeting the requirements set forth 

in VHA Directive 2007-015 is fully implemented. 

N 

Suicide Prevention Program 

9. Ensure that medical record documentation 

for patients deemed at high risk for suicide is 

in compliance with VHA and facility policy. 

The suicide prevention coordinator and case manager 

monitor veterans at high risk for suicidal behavior daily to 

ensure they have patient record flags and completed 

safety plans with subsequent reviews and timely 

follow-up. Interdisciplinary collaboration and consensus 

for high-risk cases are ensured through the suicide 

prevention coordinator’s and case manager’s attendance 

at team meetings. The suicide prevention coordinator 

and case manager assure ongoing interdisciplinary 

collaboration and communication with outpatient 

providers through telephone consultation(s) and by 

adding the providers as additional signers of their 

progress notes. 

N 

VA OIG Office of Healthcare Inspections 15 
CAP Review of the VA Illiana Health Care System, Danville, IL 

Appendix C 

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

facility performance. Patients are surveyed monthly. Table 1 below shows facility, 

VISN, and VHA overall inpatient satisfaction scores and targets for quarters 3–4 of 

FY 2010 and quarters 1–2 of FY 2011 and overall outpatient satisfaction scores and 

targets for quarter 4 of FY 2010 and quarters 1–3 of FY 2011. 

Table 1 

FY 2010 FY 2011 

Inpatient 

Score 

Quarters 3–4 

Outpatient 

Score 

Quarter 4 

Inpatient 

Score 

Quarters 1–2 

Outpatient 

Score 

Quarter 1 

Outpatient 

Score 

Quarter 2 

Outpatient 

Score 

Quarter 3 

Facility 50.1 57.9 52.6 61.0 57.0 51.9 

VISN 67.7 55.7 61.1 56.9 54.3 55.0 

VHA 64.1 54.4 63.9 55.9 55.3 54.2 

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

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

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

VA OIG Office of Healthcare Inspections 16 
CAP Review of the VA Illiana Health Care System, Danville, IL 

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

conditions received hospital care.5 Mortality (or death) rates focus on whether patients 

died within 30 days of being hospitalized. Readmission rates focus on whether patients 

were hospitalized again within 30 days of their discharge. These rates are based on 

people who are 65 and older and are “risk-adjusted” to take into account how sick 

patients were when they were initially admitted. Table 2 below shows facility and U.S. 

national Hospital Outcome of Care Measure rates for patients discharged between 

July 1, 2007, and June 30, 2010.6 

Table 2 

Mortality Readmission 

Heart Attack Congestive 

HF 

Pneumonia Heart Attack Congestive 

HF 

Pneumonia 

Facility ** 9.6 12.2 ** 26.7 20.7 

U.S. 

National 15.9 11.3 11.9 19.8 24.8 18.4 

** The number of cases is too small (fewer than 25) to reliably tell how well the facility is performing. 

5 A heart attack occurs when blood flow to a section of the heart muscle becomes blocked, and the blood supply is 

slowed or stopped. If the blood flow is not restored timely, the heart muscle becomes damaged. Congestive HF is a 

weakening of the heart’s pumping power. Pneumonia is a serious lung infection that fills the lungs with mucus and 

causes difficulty breathing, fever, cough, and fatigue.

6 Rates were calculated from Medicare data and do not include data on people in Medicare Advantage Plans (such as 

health maintenance or preferred provider organizations) or people who do not have Medicare. 

VA OIG Office of Healthcare Inspections 17 
CAP Review of the VA Illiana Health Care System, Danville, IL 

Appendix D 

VISN Director Comments 

Department of 

Veterans Affairs	 Memorandum 

Date:	 January 19, 2012 

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

Subject:	 CAP Review of the VA Illiana Health Care System, 

Danville, IL 

To:	 Director, Kansas City Office of Healthcare Inspections 

(54KC) 

Director, Management Review Service (VHA 10A4A4 

Management Review) 

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

Illiana Healthcare System. If you have any questions, please contact 

Kelley Sermak, VISN 11, Acting QMO, at (734) 222-4302. 

Michael S. Finegan 

Attachment 

VA OIG Office of Healthcare Inspections 18 
CAP Review of the VA Illiana Health Care System, Danville, IL 

Appendix E 

Acting Facility Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: January 17, 2012
 

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

Subject: CAP Review of the VA Illiana Health Care System,
 

Danville, IL 

To: VISN Director (10N11) 

Please see attached responses to report. 

(original signed by:) 

Thomas Mattice 

Acting Medical Center Director 

VA OIG Office of Healthcare Inspections 19 
CAP Review of the VA Illiana Health Care System, Danville, IL 

Comments to OIG’s Report
 

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

recommendations in the OIG report: 

OIG Recommendations 

Recommendation 1. We recommended that processes be strengthened to ensure that 

all fire exits are identified by visible signage, are not locked, and are clear of 

obstructions and not blocked. 

Concur 

Target date for completion: 12/9/2011 

Exit signs in the OR that had been removed during construction have now been 

reinstalled by Engineering staff. 

Staff has been educated on the importance of maintaining clear egress to all exits. Unit 

managers are conducting rounds daily to ensure all egresses are clear. Assessment of 

equipment needs on the units was conducted and excess equipment was removed. 

The facility requests to close this recommendation. 

Recommendation 2. We recommended that processes in the OR be strengthened to 

ensure that ceiling lights are clean and that the walls are repaired and maintained. 

Concur 

Target date for completion: 12/20/2011 

The wall in the OR has been repaired by Engineering staff. 

Ceiling lights in the OR have been cleaned. To assure that ceiling lights in the OR are 

clean, this task has been added to the newly developed checklist for cleaning of surgical 

suites to assure cleanliness is achieved and maintained daily. The nightly cleaning 

schedule and cleanliness of lights in the OR will be monitored weekly by Environmental 

Management Supervisors. 

The facility requests to close this recommendation. 

Recommendation 3. We recommended that a policy be developed and implemented 

for the CLC’s residential animal program. 

Concur 

Target date for completion: 1/31/2012 

VA OIG Office of Healthcare Inspections 20 
CAP Review of the VA Illiana Health Care System, Danville, IL 

Chief Recreation is currently revising MCM 11K-15 Service/Guide/Pet Therapy Policy. 

Revisions will include and reference programmatic responsibilities for CLC’s residential 

animal program. Cleaning and maintaining the environment properly will be based on 

specifics listed in the MCM. 

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

quarterly preventive maintenance is performed on the CLC’s elopement prevention 

system. 

Concur 

Target date for completion: 1/31/2012 

In accordance with the manufacturers’ recommendations there are no preventative 

maintenance requirements for the WanderGuard elopement prevention system; 

however, it is recommended to test the system monthly. The system was tested in 

December to assure proper function. The MCM has been updated to reflect monthly 

testing on the elopement system and is currently in the review process. Once the MCM 

has been approved, a monitor will be established to track monthly testing. 

Recommendation 5. We recommended that processes be strengthened to ensure that 

MSDS files are reviewed and updated annually. 

Concur 

Target date for completion: 2/17/2012 

All services are in the process of updating MSDS books. Once completed, the facility’s 

Industrial Hygienist will conduct a facility wide audit to ensure 100% compliance. An 

annual review schedule will be developed to assure all MSDS books remain current. A 

quick link has been added to the employee web page for easy access to the electronic 

MSDS and service chiefs were instructed to share the location of the link with staff. 

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

interdisciplinary teams develop care plans that contain all required elements. 

Concur 

Target date for completion: 12/30/2011 

The family education template was revised and approved for use. Providers are 

documenting on the TBI Evaluation or Polytrauma Support Clinic Team Consult note as 

to whether family was present and if education was provided to the family. 

The facility requests to close this recommendation. 

VA OIG Office of Healthcare Inspections 21 
CAP Review of the VA Illiana Health Care System, Danville, IL 

Recommendation 7. We recommended that the facility monitor compliance with 

polytrauma training requirements. 

Concur 

Target date for completion: 12/30/2011 

TMS education modules have been identified and assigned to Polytrauma staff for 

completion, which will satisfy polytrauma training requirements. All assigned modules 

have been completed by all Polytrauma staff. 

The facility requests to close this recommendation. 

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

clinicians document all required vaccination administration elements and that 

compliance is monitored. 

Concur 

Target date for completion: 2/17/2012 

All required elements for vaccination administration have been incorporated into the 

order entry package for in patients and clinical reminders for outpatients. A monitor has 

been developed to ensure that all required elements are documented. 

VA OIG Office of Healthcare Inspections 22 
CAP Review of the VA Illiana Health Care System, Danville, IL 

Appendix F 

OIG Contact and Staff Acknowledgments 

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

at (202) 461-4720 

Contributors	 Dorothy Duncan, RN, MHA, Project Leader 

James Seitz, RN, MBA, Team Leader 

Paula Chapman, CTRS 

Larry Seltzler, MSPT 

John Brooks, Office of Investigations 

VA OIG Office of Healthcare Inspections 23 
CAP Review of the VA Illiana Health Care System, Danville, IL 

Appendix G 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, Veterans In Partnership Network (10N11) 

Acting 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: Daniel Coates, Richard J. Durbin, Mark Kirk, Richard G. Lugar 

U.S. House of Representatives: Timothy V. Johnson, Adam Kinzinger, Todd Rokita, 

Bobby Schilling, Aaron Schock, John Shimkus 

This report is available at http://www.va.gov/oig/publications/default.asp. 

VA OIG Office of Healthcare Inspections 24