Department of Veterans Affairs

Office of Inspector General 

Office of Healthcare Inspections 

Report No. 14-04219-98 

Combined Assessment Program 

Review of the 

VA Illiana Health Care System 

Danville, Illinois 

February 2, 2015 

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 VA Illiana Health Care System, Danville, IL 

Glossary 

CAP Combined Assessment Program 

CLC community living center 

EAM emergency airway management 

EHR electronic health record 

EOC environment of care 

facility VA Illiana Health Care System 

FY fiscal year 

MH mental health 

MRI magnetic resonance imaging 

NA not applicable 

NM not met 

OIG Office of Inspector General 

QM quality management 

RRTP residential rehabilitation treatment program 

VHA Veterans Health Administration 

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

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

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

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

Coordination of Care ............................................................................................... 14
 

MRI Safety .............................................................................................................. 15
 

Acute Ischemic Stroke Care ................................................................................... 17
 

EAM ........................................................................................................................ 19
 

MH RRTP ............................................................................................................... 21
 

Review Activity with Previous CAP Recommendations ......................................... 23
 

Follow-Up on Medication Management Issue ......................................................... 23
 

Appendixes 

A. Facility Profile .................................................................................................... 24
 

B. Strategic Analytics for Improvement and Learning ............................................ 25
 

C. Veterans Integrated Service Network Director Comments ................................ 28
 

D. Facility Director Comments ............................................................................... 29
 

E. Office of Inspector General Contact and Staff Acknowledgments ..................... 36
 

F. Report Distribution ............................................................................................. 37
 

G. Endnotes ........................................................................................................... 38
 

VA OIG Office of Healthcare Inspections 
 

 

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

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 

November 3, 2014. 

Review Results: The review covered eight activities and a follow-up review area 

from the previous Combined Assessment Program review. The facility’s reported 

accomplishments were the chronic pain care school symposium and the healthy smiles 

for veterans initiative. 

Recommendations: We made recommendations in all eight of the following 

activities and in the follow-up review area: 

Quality Management: Ensure code reviews include screening for clinical issues prior to 

the code that may have contributed to the occurrence of the code. 

Environment of Care: Ensure patient care areas are clean. Document functionality 

checks of the community living center’s elopement prevention system at least every 

24 hours. 

Medication Management: Revise the policy for safe use of automated dispensing 

machines to include employee training and minimum competency requirements for 

users. 

Coordination of Care: Create/designate a committee to oversee consult management. 

Require that the Medicine, Mental Health, Surgical, and Rehabilitation Services’ 

Automated Data Processing Applications Coordinators provide training in the use of the 

computerized consult package. 

Magnetic Resonance Imaging Safety: Ensure radiologists and/or Level 2 magnetic 

resonance imaging personnel document resolution in patients’ electronic health records 

of all identified magnetic resonance imaging contraindications prior to the scan. Require 

that scanned magnetic resonance imaging documents are accurate and complete. 

Acute Ischemic Stroke Care: Develop and implement an acute ischemic stroke policy 

that addresses all required items. Complete and document National Institutes of Health 

stroke scales for each stroke patient. Screen patients for difficulty swallowing prior to 

oral intake. 

Emergency Airway Management: Revise the emergency airway management policy to 

include demonstration of competency by both direct and video laryngoscopy. Ensure 

clinician reassessment for continued emergency airway management competency 

includes reviews of clinician-specific emergency airway management data and one of 

the three required components. 

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

Mental Health Residential Rehabilitation Treatment Program: Ensure the Psychosocial 

Residential Rehabilitation Treatment Program environment is clean. Replace stained 

ceiling tiles, repair or replace damaged baseboards and wall tiles, and repair the 

emergency exit door. 

Follow-Up on Medication Management Issue: Document all required vaccination 

administration elements. 

Comments 

The Veterans Integrated Service Network and Facility Directors agreed with the 

Combined Assessment Program review findings and recommendations and provided 

acceptable improvement plans. (See Appendixes C and D, pages 28–35, 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 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 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 eight activities and a follow-up review area from the previous CAP review: 

 QM 

 EOC 

 Medication Management 

	 Coordination of Care 

 MRI Safety 

	 Acute Ischemic Stroke Care 

 EAM 

 MH RRTP 

 Follow-Up on Medication Management Issue 

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 VA Illiana Health Care System, Danville, IL 

The review covered facility operations for FY 2014 and FY 2015 through 

November 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 VA Illiana Health Care System, Danville, Illinois, Report 

No.11-03665-78, February 14, 2012). We made a repeat recommendation in 

medication management. 

During this review, we presented crime awareness briefings for 91 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 

389 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. 

Reported Accomplishments 

Chronic Pain Care School Symposium 

In September 2014, the facility hosted a regional daylong symposium, which highlighted 

chronic pain care and the Opioid Safety Initiative. The presenters were distinguished 

pain specialty physicians from VA facilities in Atlanta, GA, and Richmond, VA, and a 

clinical pain neurologist from Indianapolis, IN. The Tele-Pain symposium was broadcast 

to more than 49 VA facilities and expanded to community based outpatient clinic 

locations. 

Healthy Smiles for Veterans Initiative 

Partnering with Dental, Geriatric, and Nursing Services, the facility rolled out the healthy 

smiles for veterans initiative in the CLCs and the Green House homes. The focus was 

to increase staff awareness of oral care, reduce oral care interventions for dependent 

residents, and promote better oral care for independent residents. Oral care training 

was provided to 168 CLC staff from May through August 2014 and was accomplished 

through completion of a 1-hour module and by demonstration of competency in five 

areas. 

VA OIG Office of Healthcare Inspections 2 
CAP Review of the VA Illiana 

Results and Recommendations 

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

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, three cr

folders, and other relevant documents. The table below shows the areas reviewed for this topic. The area m

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

NM Areas Reviewed Findings Rec

There was a senior-level committee responsible for key quality, safety, and value functions that met at least quarterly and was chaired or co-chaired by the Facility Director.  The committee routinely reviewed 

aggregated data. 

 QM, patient safety, and systems redesign 

appeared to be integrated. 

NA Peer reviewed deaths met selected 

requirements:  Peers completed reviews within specified 

timeframes. 

 The Peer Review Committee reviewed 

cases receiving initial Level 2 or 3 ratings. 

 Involved providers were invited to provide 

input prior to the final Peer Review Committee determination. 

VA OIG Office of Healthcare Inspections 
CAP Review of the VA Illiana 

NM Areas Reviewed (continued) Findings Rec

Credentialing and privileging processes met selected requirements:  Facility managers reviewed privilege forms 

annually and ensured proper approval of revised forms. 

 Facility managers ensured appropriate 

privileges for licensed independent practitioners. 

 Facility managers removed licensed 

independent practitioners’ access to patients’ EHRs upon separation. 

 Facility managers properly maintained 

licensed independent practitioners’ folders. 

Observation bed use met selected requirements:  The facility gathered data regarding 

appropriateness of observation bed usage. 

 The facility reassessed observation 

criteria and/or utilization if conversions to acute admissions were consistently 25–30 percent or more. 

X The process to review resuscitation events 

met selected requirements:  An interdisciplinary committee reviewed 

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. 

 The facility collected data that measured 

performance in responding to events. 

Twelve months of Multidisciplinary Oversight Committee meeting minutes reviewed:  Code review did not include screening for 

clinical issues prior to code that may have contributed to the occurrence of the code. 

1. We recommeninclude screening the code that maoccurrence of the 

VA OIG Office of Healthcare Inspections 
CAP Review of the VA Illiana 

NM Areas Reviewed (continued) Findings Rec

NA The surgical review process met selected 

requirements:  An interdisciplinary committee with 

appropriate leadership and clinical membership met monthly to review surgical processes and outcomes. 

 The Surgical Work Group reviewed 

surgical deaths with identified problems or opportunities for improvement. 

 The Surgical Work Group reviewed 

additional data elements. 

Clinicians appropriately reported critical incidents. The safe patient handling program met selected requirements:  A committee provided program oversight.  The committee gathered, tracked, and 

shared patient handling injury data. 

The process to review the quality of entries in the EHR met selected requirements:  A committee reviewed EHR quality.  A committee analyzed data at least 

quarterly. 

 Reviews included data from most services 

and program areas. 

The policy for scanning internal forms into EHRs included the following required items:  Quality of the source document and an 

alternative means of capturing data when the quality of the document is inadequate. 

 A correction process if scanned items 

have errors. 

VA OIG Office of Healthcare Inspections 
CAP Review of the VA Illiana 

NM Areas Reviewed (continued) Findings Rec

 A complete review of scanned documents 

to ensure readability and retrievability of the record and quality assurance reviews on a sample of the scanned documents. 

Overall, if QM reviews identified significant issues, the facility took actions and evaluated them for effectiveness. Overall, senior managers actively participated in performance improvement over the past 12 months. Overall, the facility had a comprehensive, effective QM program over the past 12 months. The facility met any additional elements required by VHA or local policy. 

VA OIG Office of Healthcare Inspections 
CAP Review of the VA Illiana 

EOC The purpose of this review was to determine whether the facility maintained a clean and safe health care ewith applicable requirements. We also determined whether the facility met selected requirements in the CLCWe inspected the CLC, inpatient units (acute medicine and MH), outpatient clinics (physical therapy, prima

endoscopy suite, and the urgent care clinic. Additionally, we reviewed relevant documents and 24 CLC emp

conversed with key employees and managers. The table below shows the areas reviewed for this topic. Thnot meet applicable requirements and needed improvement. Any items that did not apply to this facility are m

NM Areas Reviewed for General EOC Findings Rec

EOC Committee minutes reflected sufficient detail regarding identified deficiencies, corrective actions taken, and tracking of corrective actions to closure for the facility and the community based outpatient clinics. The facility conducted an infection prevention risk assessment. Infection Prevention/Control Committee minutes documented discussion of identified high-risk areas, actions implemented to address those areas, and follow-up on implemented actions and included analysis of surveillance activities and data. The facility had established a process for cleaning equipment. Selected employees received training on updated requirements regarding chemical labeling and safety data sheets. The facility met fire safety requirements. 

X The facility met environmental safety 

requirements. 

 Two of seven patient care areas had dirty 

floors and horizontal surfaces. 

2. We recommenensure patient camonitor complian

VA OIG Office of Healthcare Inspections 
CAP Review of the VA Illiana 

NM Areas Reviewed for General EOC 

(continued) 

Findings Rec

The facility met infection prevention requirements. The facility met medication safety and security requirements. The facility met privacy requirements. The facility complied with any additional elements required by VHA, local policy, or other regulatory standards. 

Areas Reviewed for Critical Care 

NA Designated critical care employees received 

bloodborne pathogens training during the past 12 months. 

NA Alarm-equipped medical devices used in 

critical care were inspected/checked according to local policy and/or manufacturers’ recommendations. 

NA The facility met fire safety requirements in 

critical care. 

NA The facility met environmental safety 

requirements in critical care. 

NA The facility met infection prevention 

requirements in critical care. 

NA The facility met medication safety and 

security requirements in critical care. 

NA The facility met medical equipment 

requirements in critical care. 

NA The facility met privacy requirements in 

critical care. 

NA The facility complied with any additional 

elements required by VHA, local policy, or other regulatory standards. 

VA OIG Office of Healthcare Inspections 
CAP Review of the VA Illiana 

NM Areas Reviewed for CLC Findings Rec

Designated CLC employees received bloodborne pathogens training during the past 12 months. For CLCs with resident animal programs, the facility conducted infection prevention risk assessments and had policies addressing selected requirements. 

X For CLCs with elopement prevention 

systems, the facility documented functionality checks at least every 24 hours and documented complete system checks annually. 

 The facility did not consistently document 

functionality checks of the CLC’s elopement prevention system at least every 24 hours. 

3. We recommendocument functiocommunity living prevention system and that facility mcompliance. 

The facility met fire safety requirements in the CLC. 

X The facility met environmental safety 

requirements in the CLC. 

 Three occupied rooms had dirty floors, 

window blinds, and windowsills. 

See recommend

The facility met infection prevention requirements in the CLC. The facility met medication safety and security requirements in the CLC. The facility met medical equipment requirements in the CLC. The facility met privacy requirements in the CLC. The facility complied with any additional elements required by VHA, local policy, or other regulatory standards. 

Areas Reviewed for Construction Safety 

NA The facility met selected dust control, 

temporary barrier, storage, and security requirements for the construction site perimeter. 

VA OIG Office of Healthcare Inspections 
CAP Review of the VA Illiana 

NM Areas Reviewed for Construction Safety 

(continued) 

Findings Rec

NA The facility complied with any additional 

elements required by VHA or local policy, or other regulatory standards. 

VA OIG Office of Healthcare Inspections 
CAP Review of the VA Illiana 

Medication Management The purpose of this review was to determine whether the facility had established safe medication storage prVHA policy and Joint Commission standards.c We reviewed relevant documents, the training records of 20 nursing employees, and pharmacy monthly 

inspection documentation for the past 6 months. Additionally, we inspected the acute medicine unit, CLC, and urgent care clinic and for these areas reviewed documentation of overrides and narcotic wastage frmachines and inspected crash carts containing emergency medications. The table below shows the areas r

area marked as NM did not meet applicable requirements and needed improvement. Any items that did nmarked NA. 

NM Areas Reviewed Findings Rec

Facility policy addressed medication receipt in patient care areas, storage procedures until administration, and staff authorized to have access to medications and areas used to store them. The facility required two signatures on controlled substances partial dose wasting. The facility defined those medications and supplies needed for emergencies and procedures for crash cart checks, checks included all required elements, and the facility conducted checks with the frequency required by local policy. The facility prohibited storage of potassium chloride vials in patient care areas. If the facility stocked heparin in concentrations of more than 5,000 units per milliliter in patient care areas, the Chief of Pharmacy approved it. 

VA OIG Office of Healthcare Inspections 
CAP Review of the VA Illiana 

NM Areas Reviewed (continued) Findings Rec

The facility maintained a list of the look-alike and sound-alike medications it stores, dispenses, and administers; reviewed this list annually and ensured it was available for staff reference; and had labeling/storage processes to prevent errors. The facility identified in writing its high-alert and hazardous medications, ensured the high-alert list was available for staff reference, and had processes to manage these medications. The facility conducted and documented inspections of all medication storage areas at least every 30 days, fully implemented corrective actions, and monitored the changes. 

X The facility/Pharmacy Service had a written 

policy for safe use of automated dispensing machines that included oversight of overrides and employee training and minimum competency requirements for users, and employees received training or competency assessment in accordance with local policy. 

 Facility policy for safe use of automated 

dispensing machines did not include employee training and minimum competency requirements for users. 

4. We recommenthe policy for safe dispensing machtraining and minirequirements for managers monito

The facility employed practices to prevent wrong-route drug errors. Medications prepared but not immediately administered contained labels with all required elements. The facility removed medications awaiting destruction or stored them separately from medications available for administration. 

VA OIG Office of Healthcare Inspections 
CAP Review of the VA Illiana 

NM Areas Reviewed (continued) Findings Rec

The facility met multi-dose insulin pen requirements. The facility complied with any additional elements required by VHA or local policy. 

VA OIG Office of Healthcare Inspections 
CAP Review of the VA Illiana 

Coordination of Care The purpose of this review was to evaluate the consult management process and the completion of inpatient 

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

patients who had a consult requested during an acute care admission from January 1 through June 30, 201the areas reviewed for this topic. The areas marked as NM did not meet applicable requirements and neede

that did not apply to this facility are marked NA. 

NM Areas Reviewed Findings Rec

X A committee oversaw the facility’s consult 

management processes. 

 The facility did not have a committee to 

oversee consult management. 

5. We recommencreate/designate consult managem

X Major bed services had designated 

employees to:  Provide training in the use of the 

computerized consult package. 

 Review and manage consults. 

 The Medicine, MH, Surgical, and 

Rehabilitation Services’ Automated Data Processing Applications Coordinators did not provide training in the use of the computerized consult package. 

6. We recommenMental Health, SServices’ AutomaApplications Coothe use of the coand that facility mcompliance. 

Consult requests met selected requirements: 

 Requestors included the reason for the 

consult. 

 Requestors properly titled the requests.  Consultants appropriately changed consult 

statuses, linked responses to the requests, and completed consults within the specified timeframe. 

The facility met any additional elements required by VHA or local policy. 

VA OIG Office of Healthcare Inspections 
CAP Review of the VA Illiana 

MRI Safety The purpose of this review was to determine whether the facility ensured safety in MRI in accordance with related to: (1) staff safety training, (2) patient screening, and (3) risk assessment of the MRI environment.e We reviewed relevant documents and the training records of 40 employees (23 Level 1 ancillary staff and 1

personnel), and we conversed with key managers and employees. We also reviewed the EHRs of 35 rando

had an MRI January 1–December 31, 2013. Additionally, we conducted a physical inspection of the MRI arethe areas reviewed for this topic. The areas marked as NM did not meet applicable requirements and neede

that did not apply to this facility are marked NA. 

NM Areas Reviewed Findings Rec

The facility completed an MRI risk assessment, had documented procedures for handling emergencies in MRI, and conducted emergency drills in the MRI area. Patients had two safety screenings conducted prior to MRI; the patient, family member, or caregiver signed the secondary patient safety screening form; and a Level 2 MRI personnel reviewed and signed the secondary patient safety screening form. 

X Secondary patient safety screening forms 

contained notations of any MRI contraindications, and a Level 2 MRI personnel and/or radiologist addressed the contraindications and documented resolution prior to MRI. 

 Twenty-three of the 25 applicable EHRs 

did not contain documentation that a Level 2 MRI personnel and/or radiologist addressed all identified contraindications prior to MRI. 

7. We recommenLevel 2 magnetic personnel documelectronic health magnetic resonacontraindications facility managers 

The facility designated Level 1 ancillary staff and Level 2 MRI personnel and ensured they received level-specific annual MRI safety training. 

VA OIG Office of Healthcare Inspections 
CAP Review of the VA Illiana 

NM Areas Reviewed (continued) Findings Rec

The facility had signage and barriers 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 facility regularly tested the two-way communication device. The facility provided patients with MRI-safe hearing protection for use during the scan. The facility had only MRI-safe or compatible equipment in Zones III and IV or appropriately protected the equipment from the magnet. 

X The facility complied with any additional 

elements required by VHA or local policy. 

VHA policy on health information management and health records reviewed, which requires that patient health records are accurate and complete: 

 Six EHRs contained inaccurate and 

incomplete scanned MRI documents. 

8. We recommenresonance imagiand complete anmonitor complian

VA OIG Office of Healthcare Inspections 
CAP Review of the VA Illiana 

Acute Ischemic Stroke Care The purpose of this review was to determine whether the facility complied with selected requirements for the of patients who had an acute ischemic stroke.f We reviewed relevant documents, the EHRs of 13 patients who experienced stroke symptoms, and 10 (five urgent care clinic and five acute medicine unit), and we conversed with key employees. We also condthe urgent care clinic, the acute medicine unit, three MH units, and seven CLC units. The table below shows 

topic. The areas marked as NM did not meet applicable requirements and needed improvement. Any itemfacility are marked NA. 

NM Areas Reviewed Findings Rec

X The facility’s stroke policy addressed all 

required items. 

 The facility did not have a policy in place 

that addressed the management of acute ischemic stroke. 

9. We recommenand implement apolicy that addre

X Clinicians completed the National Institutes 

of Health stroke scale for each patient within the expected timeframe. 

 For two of the eight applicable patients, 

clinicians did not document evidence of completed stroke scales. 

10. We recommecomplete and doof Health stroke spatient and that fcompliance. 

NA Clinicians provided medication (tissue 

plasminogen activator) timely to halt the stroke and included all required steps, and the facility stocked tissue plasminogen activator in appropriate areas. Facility managers posted stroke guidelines in all areas where patients may present with stroke symptoms. 

X Clinicians screened patients for difficulty 

swallowing prior to oral intake of food or medicine. 

 For three of the nine applicable patients, 

clinicians did not document in the EHRs that they screened the patients for difficulty swallowing prior to oral intake. 

11. We recommepatients for difficintake and that facompliance. 

Clinicians provided printed stroke education to patients upon discharge. 

VA OIG Office of Healthcare Inspections 
CAP Review of the VA Illiana 

NM Areas Reviewed (continued) Findings Rec

The facility provided training to employees involved in assessing and treating stroke patients. The facility collected and reported required data related to stroke care. The facility complied with any additional elements required by VHA or local policy. 

VA OIG Office of Healthcare Inspections 
CAP Review of the VA Illiana 

EAM The purpose of this review was to determine whether the facility complied with selected VHA out of operating 

requirements.g 

We reviewed relevant documents, including competency assessment documentation of six clinicians applic

January 1 through June 30, 2014, and we conversed with key managers and employees. The table below 

for this topic. The areas marked as NM did not meet applicable requirements and needed improvement. Ato this facility are marked NA. 

NM Areas Reviewed Findings Rec

The facility had a local EAM policy or had a documented exemption. 

NA If the facility had an exemption, it did not 

have employees privileged to perform procedures using moderate or deep sedation that might lead to airway compromise. Facility policy designated a clinical subject matter expert, such as the Chief of Staff or Chief of Anesthesia, to oversee EAM. 

X Facility policy addressed key VHA 

requirements, including: 

 Competency assessment and 

reassessment processes. 

 Use of equipment to confirm proper 

placement of breathing tubes. 

 A plan for managing a difficult airway. 

 Facility policy did not address that 

competency assessment must be demonstrated with both direct and video laryngoscopy. 

12. We recommethe emergency ainclude demonstrboth direct and v

NA Initial competency assessment for EAM 

included:  Subject matter content elements and 

completion of a written test. 

 Successful demonstration of procedural 

skills on airway simulators or mannequins. 

 Successful demonstration of procedural 

skills on patients. 

VA OIG Office of Healthcare Inspections 
CAP Review of the VA Illiana 

NM Areas Reviewed (continued) Findings Rec

X Reassessments for continued EAM 

competency were completed at the time of renewal of privileges or scope of practice and included:  Review of clinician-specific EAM data.  Subject matter content elements and 

completion of a written test. 

 Successful demonstration of procedural 

skills on airway simulators or mannequins. 

 At least one occurrence of successful 

airway management and intubation in the 

 Neither of the two applicable clinicians 

had clinician-specific EAM data reviewed. 

 None of the six clinicians had evidence of 

successful airway management and intubation of at least one patient in the preceding 2 years, written certification of airway management competency from the evaluating supervisor at the non-VA facility, or successful demonstration of airway management and intubation skills to the facility subject matter expert. 

13. We recommeclinician reassesemergency airwaincludes reviews emergency airwathat facility mana14. We recommethat clinician reasemergency airwaincludes one of thcomponents and 

preceding 2 years, written certification of competency by the supervisor, or successful demonstration of skills to the subject matter expert. 

 A statement related to EAM if the clinician 

was not a licensed independent practitioner. 

monitor complian

The facility had a clinician with EAM privileges or scope of practice available during all hours the facility provided patient care. Video equipment to confirm proper placement of breathing tubes was available for immediate clinician use. The facility complied with any additional elements required by VHA or local policy. 

VA OIG Office of Healthcare Inspections 
CAP Review of the VA Illiana 

MH RRTP The purpose of this review was to determine whether the facility’s Psychosocial RRTP complied with selected We reviewed relevant documents, inspected the Psychosocial RRTP, and conversed with key employees. Tareas reviewed for this topic. The area marked as NM did not meet applicable requirements and needed im

did not apply to this facility are marked NA. 

NM Areas Reviewed Findings Rec

X The residential environment was clean and 

in good repair. 

 The Psychosocial RRTP had dirty ceiling 

vents and floor baseboards, and the emergency exit door in the alcove of the women’s wing was dirty. 

 The Psychosocial RRTP had stained 

ceiling tiles, damaged baseboards, and chipped wall tiles, and the emergency exit door sensor device wiring in the alcove of the women’s wing needed repair. 

15. We recommeensure the PsychRehabilitation Treenvironment is clcompliance. 16. We recommethat PsychosociaTreatment Prograreplaced, damagwall tiles are repaemergency exit d

NA Appropriate fire extinguishers were available 

near grease producing cooking devices. There were policies/procedures that addressed safe medication management and contraband detection. MH RRTP employees conducted and documented monthly MH RRTP self-inspections that included all required elements, submitted work orders for items needing repair, and ensured correction of any identified deficiencies. 

VA OIG Office of Healthcare Inspections 
CAP Review of the VA Illiana 

NM Areas Reviewed (continued) Findings Rec

MH RRTP employees conducted and documented contraband inspections, rounds of all public spaces, daily bed checks, and resident room inspections for unsecured medications. The MH RRTP had written agreements in place acknowledging resident responsibility for medication security. MH RRTP main point(s) of entry had keyless entry and closed circuit television monitoring, and all other doors were locked to the outside and alarmed. The MH RRTP had closed circuit television monitors with recording capability in public areas but not in treatment areas or private spaces and signage alerting veterans and visitors of recording. There was a process for responding to behavioral health and medical emergencies, and MH RRTP employees could articulate the process. In mixed gender MH RRTP units, women veterans’ rooms had keyless entry or door locks, and bathrooms had door locks. Residents secured medications in their rooms. The facility complied with any additional elements required by VHA or local policy. 

VA OIG Office of Healthcare Inspections 
CAP Review of the VA Illiana 

Review Activity with Previous CAP Recommendation

Follow-Up on Medication Management Issue As a follow-up to a recommendation from our prior CAP review, we reassessed facility compliance with vacci

reviewed documentation of selected vaccine administration requirements and conversed with key personnel. 

Vaccination Documentation. Federal law requires that documentation for administered vaccinations include the vaccine manufacturer and lot number of the vaccine used.i The facility reported that their most rec

January 1 through March 31, 2014, indicated that clinicians did not document all required elements in 33 

69 percent of tetanus vaccination records. Recommendation 17. We recommended that clinicians document all required vaccination administration elements and that 

compliance. 

VA OIG Office of Healthcare Inspections 
 

 

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

Appendix A 

Facility Profile (Danville/550) FY 2015 through 

November 20141 

Type of Organization Secondary 

Complexity Level 2-Medium complexity 

Affiliated/Non-Affiliated Affiliated 

Total Medical Care Budget in Millions $181.3 

Number of: 

 Unique Patients 18,674 

 Outpatient Visits 49,933 

 Unique Employees2 1,192 

Type and Number of Operating Beds (as of October): 

 Hospital 79 

 CLC 217 

 MH 35 

Average Daily Census (as of October): 

 Hospital 25 

 CLC 91 

 MH 34 

Number of Community Based Outpatient Clinics 5 

Location(s)/Station Number(s) Peoria/550BY 

Decatur/550GA 

West Lafayette/550GC 

Springfield/550GD 

Mattoon/550GF 

Veterans Integrated Service Network Number 11 

1

 All data is for FY 2015 through November 2014 except where noted. 

2

 Unique employees involved in direct medical care (cost center 8200) from most recent pay period. 

VA OIG Office of Healthcare Inspections 24 
CAP Review of the VA Illiana Health C

Strategic Analytics for Improvement and Learning (SAIL)3 

3 Metric definitions follow the graphs. 

VA OIG Office of Healthcare Inspections 
CAP Review of the VA Illiana 

Scatter Chart 

FY2014Q3 Quintile 

VA OIG Office of Healthcare Inspections 
CAP Review of the VA Illiana 

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 VA Illiana Health Care System, Danville, IL 

Appendix C 

Veterans Integrated Service Network Director Comments 

Department of 

Veterans Affairs Memorandum

Date: January 8. 2015 

From: Director, Veterans in Partnership (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 10AR MRS OIG CAP 

CBOC) 

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

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

Carol Jones, VISN 11, Quality Management Officer at (734) 222-4302. 

VA OIG Office of Healthcare Inspections 28 
CAP Review of the VA Illiana Health Care System, Danville, IL 

Appendix D 

Facility Director Comments 

Department of 

Veterans Affairs Memorandum

Date: January 2, 2015 

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

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

To: Director, Veterans in Partnership (10N11) 

Attached is a response to the draft CAP report from VA Illiana Healthcare 

System. If you have any questions, please contact Alissa Broderick, 

Chief, Quality Management at (217) 554-5083. 

(original signed by:) 

Japhet C. Rivera 

VA OIG Office of Healthcare Inspections 29 
CAP Review of the VA Illiana Health Care System, Danville, IL 

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 code reviews include screening for 

clinical issues prior to the code that may have contributed to the occurrence of the code. 

Concur 

Target date for completion: January 31, 2015 

Facility response: Following a code event, Quality Management staff will conduct a 

review of the episode, inclusive of screening for clinical issues that may have been 

present prior to the code. Each review of a code event will be presented to the 

Multidisciplinary Oversight Committee for review and approval. 

Recommendation 2. We recommended that facility managers ensure patient care 

areas are clean and monitor compliance. 

Concur 

Target date for completion: June 1, 2015 

Facility response: The current process of weekly inspections of work assignments by 

Housekeeping Supervisors will continue with the results being documented on an excel 

spreadsheet for monitoring purposes and communicated to the managers of these 

areas. Follow up communication with the managers of these areas will occur once 

deficiencies have been completed. This process will be implemented and monitored 

thru June 1, 2015. 

Recommendation 3. We recommended that the facility document functionality checks 

of the community living center’s elopement prevention system at least every 24 hours 

and that facility managers monitor compliance. 

Concur 

Target date for completion: March 31, 2015 

Facility response: The wanderguard functionality check has been added to the face 

check sheet for ward CLC-8 and is to be checked and initialed by staff once daily. The 

wanderguard functionality checks are monitored daily per the Nurse Manager by 

reviewing the rounding sheets. Monitoring will be conducted thru March 31, 2015 to 

ensure daily sustained compliance is achieved. 

VA OIG Office of Healthcare Inspections 30 
CAP Review of the VA Illiana Health Care System, Danville, IL 

Recommendation 4. We recommended that the facility revise the policy for safe use of 

automated dispensing machines to include employee training and minimum 

competency requirements for users and that facility managers monitor compliance. 

Concur 

Target date for completion: April 30, 2015 

Facility response: The facility policy for automated dispensing machines will be revised 

to include 100 percent pharmacy ownership of all Automated Dispensing Machine 

account creation and access. Additionally, the current policy will be updated to specify 

that access will only be granted upon confirmation statement that minimum competency 

standards for the Automated Dispensing Machine have been completed. Monitoring will 

be conducted thru April 30, 2015 to ensure sustained compliance is achieved with the 

revised process. 

Recommendation 5. We recommended that the facility create/designate a committee 

to oversee consult management. 

Concur 

Target date for completion: March 31, 2015 

Facility response: A Consult Management Committee has been chartered and is 

designated to receive, monitor, analyze and address all aspects of consult management 

to meet the facility’s mission and commitment to timeliness of care, provide support to 

enhance communication of Veteran needs and outcome of treatment. This committee 

will meet monthly and report to Access Committee. 

Recommendation 6. We recommended that the Medicine, Mental Health, Surgical, 

and Rehabilitation Services’ Automated Data Processing Applications Coordinators 

provide training in the use of the computerized consult package and that facility 

managers monitor compliance. 

Concur 

Target date for completion: March 31, 2015 

Facility response: The staff in the role of Automated Data Processing Application 

Coordinators (ADPAC) in the services identified above will provide training in the use of 

the computerized consult package and provide evidence of this training in their staff 

meeting minutes at a minimum of annually. The identified services will be required to 

provide evidence of training to the Consult Management Committee annually to ensure 

there is sustained improvement and that training is completed. Compliance will be 

monitored by all the above listed services providing documentation that required 

education has been completed and will be submitted to Consult Management 

Committee by March 31, 2015. 

VA OIG Office of Healthcare Inspections 31 
 

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

Recommendation 7. We recommended that radiologists and/or Level 2 magnetic 

resonance imaging personnel document resolution in patients’ electronic health records 

of all identified magnetic resonance imaging contraindications prior to the scan and that 

facility managers monitor compliance. 

Concur 

Target date for completion: March 31, 2015 

Facility response: Education has been provided to the Magnetic Resonance Imaging 

Technologists on accurate and proper documentation concerning contraindications for 

Magnetic Resonance Imaging exams by the Imaging Supervisor. Monitoring will be 

conducted by the Imaging Supervisor thru March 31, 2015 to ensure sustained 

improvement is achieved. 

Recommendation 8. We recommended that scanned magnetic resonance imaging 

documents are accurate and complete and that facility managers monitor compliance. 

Concur 

Target date for completion: March 31, 2015 

Facility response: Education to staff was provided by the Medical Records staff on 

accurate and proper documentation that is required to be included on scanned records. 

Imaging Picture Archiving Communication Systems Manager and/or designee will 

review every Magnetic Resonance Imaging safety screening form to ensure proper 

documentation has been completed prior to scanning. Imaging staff that scan 

documents into the patient’s record will thoroughly double check that each scanned 

document matches that patient’s record. Monitoring will be conducted by Imaging 

Supervisor thru March 31, 2015 to ensure sustained compliance is achieved. 

Recommendation 9. We recommended that the facility develop and implement an 

acute ischemic stroke policy that addresses all required items. 

Concur 

Target date for completion: March 31, 2015 

Facility response: An Acute Ischemic Stroke Management policy has been developed 

and is currently in the approval process. The policy establishes a protocol to implement 

a standardized approach to provide efficient, expedient, quality care for the patients 

developing signs and symptoms of acute stroke. 

VA OIG Office of Healthcare Inspections 32 
CAP Review of the VA Illiana Health Care System, Danville, IL 

Recommendation 10. We recommended that clinicians complete and document 

National Institutes of Health stroke scales for each stroke patient and that facility 

managers monitor compliance. 

Concur 

Target date for completion: April 30, 2015 

Facility response: A monitor is being developed to ensure that clinicians complete and 

document National Institute for Health stroke scales for each stroke patient within the 

expected timeframe. Monitor results will be provided to Quality Management by 

Nursing Service for review to ensure sustained compliance is achieved. Monitoring will 

be reported at the Multidisciplinary Committee thru April 30, 2015 to ensure sustained 

compliance is achieved. 

Recommendation 11. We recommended that clinicians screen patients for difficulty 

swallowing prior to oral intake and that facility managers monitor compliance. 

Concur 

Target date for completion: April 30, 2015 

Facility response: The dysphagia screen is currently included in the National Institutes 

of Health stroke assessment. Completion of this screening tool and monitor results will 

be provided to the Multidisciplinary Oversight Committee by Nursing Service monthly for 

review to ensure sustained compliance is achieved. 

Recommendation 12. We recommended that the facility revise the emergency airway 

management policy to include demonstration of competency by both direct and video 

laryngoscopy. 

Concur 

Target date for completion: March 31, 2015 

Facility response: Facility policy 112-03, Out of Operating Room Airway Management 

has been revised to include demonstration of competency by both direct and video 

laryngoscopy. The policy is currently beginning the facility approval process. 

Recommendation 13. We recommended that the facility ensure clinician 

reassessment for continued emergency airway management competency includes 

reviews of clinician-specific emergency airway management data and that facility 

managers monitor compliance. 

Concur 

Target date for completion: April 30, 2015 

VA OIG Office of Healthcare Inspections 33 
CAP Review of the VA Illiana Health Care System, Danville, IL 

Facility response: The clinician assessment for continued emergency airway 

management competency has been revised and will include reviews of clinician specific 

emergency airway management data. Compliance will be monitored by Surgery 

Service thru April 30, 2015 to ensure adherence to approved revisions and 

requirements. 

Recommendation 14. We recommended that the facility ensure that clinician 

reassessment for continued emergency airway management competency includes one 

of the three required components and that facility managers monitor compliance. 

Concur 

Target date for completion: April 30, 2015 

Facility response: The clinician reassessment for continued emergency airway 

management competency includes one of the three required components. Compliance 

will be monitored by Surgery Service thru April 30, 2015 to ensure adherence to 

approved revisions and requirements. 

Recommendation 15. We recommended that facility managers ensure the 

Psychosocial Residential Rehabilitation Treatment Program environment is clean and 

monitor compliance. 

Concur 

Target date for completion: June 1, 2015 

Facility response: The Chief, Environmental Management Service will coordinate 

weekly inspections of this area and ensure results are documented on an excel 

spreadsheet and communicated with the Coordinator of the Psychosocial Residential 

Rehabilitation Treatment Program. This weekly inspection of this area will continue and 

be monitored thru June 1, 2015. 

Recommendation 16. We recommended that the facility ensure that Psychosocial 

Residential Rehabilitation Treatment Program stained ceiling tiles are replaced, 

damaged baseboards and chipped wall tiles are repaired or replaced, and the 

emergency exit door is repaired. 

Concur 

Target date for completion: February 28, 2015. 

Facility response: A walk through of the Psychosocial Residential Rehabilitation 

Treatment Program has been conducted by Engineering staff to review and monitor 

work that has been completed to date. All remaining identified issues will be resolved 

by Engineering staff by February 28, 2015. 

VA OIG Office of Healthcare Inspections 34 
CAP Review of the VA Illiana Health Care System, Danville, IL 

Recommendation 17. We recommended that clinicians document all required 

vaccination administration elements and that facility managers monitor compliance. 

Concur 

Target date for completion: June 30, 2015 

Facility response: A progress note is being developed that will capture all required 

vaccination administration elements. Once approved, education will be provided to all 

clinicians who will be responsible for entering the required information, prior to 

implementation of the progress note. Monitoring by Nursing Service is being 

established to ensure all required vaccination administration elements are documented 

consistently for all vaccinations and will be conducted thru June 30, 2015. 

VA OIG Office of Healthcare Inspections 35 
CAP Review of the VA Illiana Health Care System, Danville, IL 

Appendix E 

Office of Inspector General 

Contact and Staff Acknowledgments 

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

at (202) 461-4720. 

Inspection Team Cindy Niemack-Brown, LCSW, LMHP, Team Leader 

Stephanie Hensel, RN, JD 

James Seitz, RN, MBA 

Larry Selzler, MSPT 

Laura Snow, LCSW, MHCL 

Steven L. Wilson, Resident Agent in Charge, Office of 

Investigations 

Other Elizabeth Bullock 

Contributors Shirley Carlile, BA 

Paula Chapman, CTRS 

Lin Clegg, PhD 

Marnette Dhooghe, MS 

Patrick Smith, M. Stat 

Julie Watrous, RN, MS 

Jarvis Yu, MS 

VA OIG Office of Healthcare Inspections 36 
CAP Review of the VA Illiana Health Care System, Danville, IL 

Appendix F 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, Veterans in Partnership (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: Daniel Coats, Joe Donnelly, Richard J. Durbin, Mark Kirk 

U.S. House of Representatives: Larry Bucshon, Cheri Bustos, Rodney Davis, 

Adam Kinzinger, Todd Rokita, Aaron Schock, John Shimkus 

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

VA OIG Office of Healthcare Inspections 37 
 

 

 

 

 

 

 

 

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

Appendix G 

Endnotes 

a

 References used for this topic included: 

	 VHA Directive 1026, VHA Enterprise Framework for Quality, Safety, and Value, August 2, 2013. 

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

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

	 VHA Directive 2010-032, Safe Patient Handling Program and Facility Design, June 28, 2010. 

	 VHA Directive 1036, Standards for Observation in VA Medical Facilities, February 6, 2014. 

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

	 VHA Handbook 1102.01, National Surgery Office, January 30, 2013. 

	 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, July 22, 2014. b

 References used for this topic included: 

	 VHA Directive 2010-052, Management of Wandering and Missing Patients, December 3, 2010. 

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

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

June 11, 2009. 

	 Various requirements of The Joint Commission, the Occupational Safety and Health Administration, 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 Directive 2008-027, The Availability of Potassium Chloride for Injection Concentrate USP, May 13, 2008. 

	 VHA Directive 2010-020, Anticoagulation Therapy Management, May 14, 2010. 

	 VHA Handbook 1108.01, Controlled Substances (Pharmacy Stock), November 16, 2010. 

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

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

	 VHA Handbook 1108.07, Pharmacy General Requirements, April 17, 2008. 

	 Various requirements of The Joint Commission. d

 The reference used for this topic was: 

	 Under Secretary for Health, “Consult Business Rule Implementation,” memorandum, May 23, 2013. e

 References used for this topic included: 

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

	 VHA Handbook 1907.01. 

	 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. f

 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. g

 References used for this topic included: 

	 VHA Directive 2012-032, Out of Operating Room Airway Management, October 26, 2012. 

	 VHA Handbook 1101.04, Medical Officer of the Day, August 30, 2010. 

VA OIG Office of Healthcare Inspections 38 
 

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

h

 References used for this topic were: 

 VHA Handbook 1162.02, Mental Health Residential Rehabilitation Treatment Program (MH RRTP), 

December 22, 2010. 

	 VHA Handbook 1330.01, Health Care Services for Women Veterans, May 21, 2010. 

	 Requirements of the VHA Center for Engineering and Occupational Safety and Health and the National Fire 

Protection Association. i

The reference used for this topic was: 

	 National Childhood Vaccine Injury Act of 1986, sub part C. 

VA OIG Office of Healthcare Inspections 39