Department of Veterans Affairs 

Office of Inspector General 

Healthcare Inspection 

Oversight of the Community Nursing 

Home Program 

VA North Texas Health Care System 

Dallas, Texas 

Report No. 07-01922-180 August 12, 2008

VA Office of Inspector General 

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

Call the OIG Hotline – (800) 488-8244 
Oversight of the Community Nursing Home Program VA North Texas Health Care System, Dallas, Texas 

Executive Summary 

The VA Office of Inspector General, Office of Healthcare Inspections conducted a 

review to determine the validity of allegations regarding poor quality of care and 

inadequate oversight provided to veterans in the Community Nursing Home (CNH) 

Program at VA North Texas Health Care System (the system). 

The ongoing monitoring of patients in CNHs assesses the overall quality of care provided 

in nursing facilities and assists with the coordination of care. We substantiated that the 

system failed to conduct follow-up visits every 30 days. We also substantiated the CNH 

Program at the system did not consistently analyze available information for annual 

inspections and evaluate exclusion criteria. 

We recommended that management comply with Veterans Health Administration 

Handbook 1143.2, VHA Community Nursing Home Oversight Procedures, concerning 

follow-up visits every 30 days and CNH annual inspections and evaluation of exclusion 

criteria. Management concurred with the recommendations and implemented acceptable 

action plans. 

VA Office of Inspector General i 
DEPARTMENT OF VETERANS AFFAIRS

Office of Inspector General 

Washington, DC 20420 

TO: Director, Veterans Integrated Service Network (10N17) 

SUBJECT: Healthcare Inspection – Oversight of the Community Nursing Home 

Program, VA North Texas Health Care System, Dallas, Texas 

Purpose 

The VA Office of Inspector General (OIG), Office of Healthcare Inspections conducted a 

review to determine the validity of allegations concerning inadequate oversight provided 

to veterans in the Community Nursing Home (CNH) Program at VA North Texas Health 

Care System (the system) located in Dallas, TX. 

Background 

The system is a tertiary care facility that provides a full range of healthcare services in 

medicine, surgery, mental health, and rehabilitation medicine. The system is also a major 

referral center, has eight community-based outpatient clinics, and has contracts with 37 

nursing facilities within the community. The system is part of Veterans Integrated 

Service Network (VISN) 17. 

The OIG Hotline Division received a complaint that alleged the system’s CNH Program 

provided poor quality of care and inadequate oversight to the CNHs. According to the 

complainant, the system is not in compliance with Veterans Health Administration 

(VHA) Handbook 1143.2, VHA Community Nursing Home Oversight Procedures, issued 

June 4, 2004, that describes specific standards and guidelines for facilities to incorporate 

in the CNH Program. 

Scope and Methodology 

We interviewed the complainant, patients, family members, and system staff. We 

reviewed CNH policies and procedures, quality management (QM) data, and CNH 

committee minutes. We also reviewed the medical records for 10 CNH patients who had 

adverse events and QM reviews related to 5 CNH patients. 

VA Office of Inspector General 1 
Oversight of the Community Nursing Home Program VA North Texas Health Care System, Dallas, Texas 

On May 17–18, 2007, we conducted onsite reviews at five CNH facilities where system 

patients were residents. We observed the environment of care, communication between 

patients and staff, patient hygiene and physical appearance, and patient activities. We 

interviewed physicians and nursing staff who were involved in the care of the patients. In 

addition, we reviewed the Centers for Medicare and Medicaid Services (CMS) 

information for the five CNH facilities. This includes CMS’ Nursing Home Compare 

database,1

 which also includes the Minimum Data Set Quality Indicator Profile. 

We conducted the inspection in accordance with Quality Standards for Inspections

published by the President’s Council on Integrity and Efficiency. 

Inspection Results 

Issue 1: CNH Follow-Up Visits 

System staff did not conduct follow-up visits every 30 days as directed in VHA 

Handbook 1143.2. The handbook states that a registered nurse or social worker must 

visit the patients in CNHs at least every 30 days, except when specific criteria apply. 

Social workers and nurses are to alternate monthly visits unless otherwise indicated by 

the patient’s visit plan. The purpose of these visits is to assess the overall quality of care 

provided in the CNH and to evaluate the system’s patients. Accuracy and timeliness of 

documentation of the visits are important to monitor the patient’s medical condition and 

coordination of care. 

We reviewed 10 medical records and did not find documentation of regular monthly 

visits for 6 patients. In addition, despite the use of templates for CNH progress notes, 

documentation at times lacked relevant clinical updates on patient’s condition. 

Issue 2: Notification of Adverse/Sentinel Events 

CNHs did not notify the system in a timely manner when a veteran was involved in an 

adverse or sentinel event.2

 At the time of our review, the system did not have an 

effective communication process to ensure that CNHs contact the system regarding 

untoward events. Currently, CNH facilities are contractually responsible for notifying 

the system in a timely manner of unexpected clinical events such as adverse and sentinel 

events, hospitalizations, and deaths of patients. We reviewed the medical records of 10 

patients who experienced unexpected clinical events. Nine of the records did not have 

documentation to support that CNH managers had notified the system of the 

adverse/sentinel events. While CNH managers were aware of the required process, they 

were unable to explain the reason for not informing the system of the events. 

 

1

 This data is available at http://www.medicare.gov/nhcompare/home.asp. 2

 Sentinel events include but are not limited to: falls resulting in injury, the patient being missing; a possibility of 

patient abuse; a medication error resulting in patient illness or injury; patient injuries related to restraint usage; or 

patient death from unconfirmed or suspicious causes. 

VA Office of Inspector General 2 
Oversight of the Community Nursing Home Program VA North Texas Health Care System, Dallas, Texas 

Issue 3: Oversight of the CNH Program 

The CNH Review Team did not consistently analyze Nursing Home Compare 

information and Minimum Data Set Quality Indicator Profile data from state survey 

reports. 

When making decisions for continuation of a CNH’s participation with the system, the 

CNH Review Team is to consider deficiencies, staffing, and quality measure information 

from Nursing Home Compare; concerns from patients, families, and ombudsman offices; 

and findings from its own experience through the monthly monitoring process. VHA 

Handbook 1143.2 states that nursing facilities are to be excluded from participating in the 

CNH Program if the facility does not meet state requirements in four of seven CMS 

review standards. The system did not consistently analyze the most recent available 

information before a contract was renewed and during annual inspections to determine 

whether factors for exclusion from the program applied. 

During 2005 through 2007, the system had contracts with up to 52 nursing facilities. 

Two of the five CNHs we visited did not meet state requirements in four of seven CMS 

review standards in 2006. The CNH Review Team did not follow up on the facilities’ 

corrective action plans to address the deficiencies. The system recently allowed the 

contracts with both of these nursing facilities to expire after continued noncompliance 

with state standards. 

Issue 4: CNH Program Staff Education and Training 

At the time of our review, we identified that CNH Program staff needed education and 

ongoing training regarding CNH policies and procedures. The newly appointed CNH 

Coordinator also identified this need for staff education and training. The CNH 

Coordinator and other system staff developed education and training programs to address 

staff competency deficiencies and initiated actions to strengthen the quality of the CNH 

patient follow-up process. 

Issue 5: External Review Assistance 

System leadership rejected a suggestion for an external review team to determine whether 

quality of care issues existed throughout the CNH Program. However, the system 

appointed a new ad hoc member to the CNH Oversight Committee in November 2006. 

The ad hoc member was an internal consultant who worked with CNH Program staff for 

several months developing processes to improve program quality and effectiveness. 

Conclusions 

We concluded that the CNH Program was not in compliance with VHA policy 

requirement that a nurse or social worker visit patients in CNH facilities on a regular 

basis. The system was not in compliance with VHA Handbook 1143.2 regarding annual 

VA Office of Inspector General 3 
Oversight of the Community Nursing Home Program VA North Texas Health Care System, Dallas, Texas 

inspections and exclusion criteria of nursing facilities when participating in the CNH 

Program. 

We identified a need for CNH staff education and training; however, system managers 

were taking action to address these deficiencies. Additionally, an internal consultant 

worked with CNH Program staff to develop processes to improve program quality and 

effectiveness. 

Recommendations 

Recommendation 1. We recommend that the VISN Director ensure that the System 

Director requires CNH Program compliance with VHA Handbook 1143.2 regarding 

follow-up visits every 30 days and ongoing monitoring. 

Recommendation 2. We recommend that the VISN Director ensure that the System 

Director requires CNH Program compliance with VHA Handbook 1143.2 regarding 

CNH annual inspections and evaluation of exclusion criteria. 

Comments 

The VISN and System Directors agreed with the findings and recommendations and 

provided acceptable improvement plans to comply with Veterans Health Administration 

Handbook 1143.2 concerning follow-up visits every 30 days, and CNH annual 

inspections and evaluation of exclusion criteria. (See Appendixes A and B, pages 5–9, 

for the full text of comments.) We will follow up on the planned actions until they are 

completed. 

 (original signed by:) 

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

Assistant Inspector General for 

Healthcare Inspections 

VA Office of Inspector General 4 
Oversight of the Community Nursing Home Program VA North Texas Health Care System, Dallas, Texas

Appendix A 

VISN Director Comments 

Department of 

Veterans Affairs Memorandum

Date: June 30, 2008 

From: Network Director, VA Heart of Texas Health Care Network, 

Arlington, TX (10N17/00)

Subject: Healthcare Inspection – Oversight of the Community Nursing 

Home Program, VA North Texas Health Care System, Dallas, 

Texas 

To: John D. Daigh, Jr., M.D., Assistant Inspector General for 

Healthcare Inspections 

We concur with OIG’s findings and recommendations. Please see attached 

responses. 

For additional information, please contact Deborah Antai-Otong VISN 17 

Continuous Readiness Officer, 817 385 3794 

VA Office of Inspector General 5 
Oversight of the Community Nursing Home Program VA North Texas Health Care System, Dallas, Texas

VISN Director’s Comments 

to Office of Inspector General’s Report 

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

recommendations in the Office of Inspector General’s report: 

OIG Recommendations

Recommendation 1. We recommend that the VISN Director 

ensure that the System Director requires CNH Program compliance 

with VHA Handbook 1143.2 regarding follow-up visits every 30 

days and ongoing monitoring. 

Concur Target Completion Date: June 30, 2008 

The health care system CNH Program Coordinator continues to 

conduct monthly audits in CPRS to monitor follow up visits from a 

nurse or social worker every 30 day in compliance with VHA 

Directive 1143.2. The CNH Coordinator also tracks and discusses 

findings at the quarterly Contract Nursing Home Oversight 

Committee meetings. The HCS will submit monthly reports to the 

VISN office for review and oversight. 

Recommendation 2. We recommend that the VISN Director 

ensure that the System Director requires CNH Program compliance 

with VHA Handbook 1143.2 regarding CNH annual inspections and 

evaluation of exclusion criteria. 

Concur Target Completion Date: June 30, 2008 

The HCS continues to make decisions concerning the continuation 

of nursing facility participation in the CNH program as stipulated by 

VHA Handbook 1143.2. The CNH Program Coordinator also 

conducts reviews and reports quarterly findings to the CNH 

Oversight Committee. However, when significant findings occur, the 

CNH Coordinator will immediately notify the Director, Chief of 

Staff and CNH Oversight Committee. The CNH Oversight 

Committee will submit minutes from quarterly meetings to the 

minutes from the CNH VISN for review and oversight. 

VA Office of Inspector General 6 
Oversight of the Community Nursing Home Program VA North Texas Health Care System, Dallas, Texas

Appendix B 

System Director Comments 

Department of 

Veterans Affairs Memorandum

Date: June 27, 2008 

From: Director, Dallas, Veterans Administration Healthcare System 

Subject: Healthcare Inspection – Oversight of the Community Nursing 

Home Program, VA North Texas Health Care System, Dallas, 

Texas 

To: Assistant Inspector, General for Healthcare Inspections 

Please find our responses to all recommendations noted in the Hotline 

Report for Oversight to the Community Nursing Homes at Dallas VA 

Medical Center.

VA Office of Inspector General 7 
Oversight of the Community Nursing Home Program VA North Texas Health Care System, Dallas, Texas 

System Director’s Comments 

to Office of Inspector General’s Report 

The following System Director’s comments are submitted in response to 

the recommendations in the Office of Inspector General’s report: 

OIG Recommendations

Recommendation 1. We recommend that the VISN Director 

ensure that the System Director requires CNH Program compliance 

with VHA Handbook 1143.2 regarding follow-up visits every 30 

days and ongoing monitoring. 

Concur Target Completion Date: June 1, 2007 

The CNH Program Coordinator now ensures each patient enrolled in 

the CNH Program receives a follow up visit from a nurse or social 

worker every 30 days, in compliance with VHA Directive 1143.2. 

In addition, the CNH Program Coordinator monitors the completion 

of follow up visits through monthly reports and random audits of 

medical records at the facility and in CPRS. The CNH Review 

Team and CNH Oversight Committee discuss this information 

quarterly. These actions have been ongoing since the OIG conducted 

its site visit in May 2007. 

Recommendation 2. We recommend that the VISN Director 

ensure that the System Director requires CNH Program compliance 

with VHA Handbook 1143.2 regarding CNH annual inspections and 

evaluation of exclusion criteria. 

Concur Target Completion Date: June 1, 2007 

When making decisions regarding the continuation of nursing facility 

participation in the CNH Program, the CNH Review Team and CNH 

Oversight Committee consistently analyze Nursing Home Compare 

information, Minimum Data Set Quality Indicator Profile data from 

state survey reports, and other quality indicator data collected from 

personal experience and program participation. Further, the CNH 

Review Team now considers patient and family satisfaction data 

obtained through monthly interactions with patients and families and 

annual family satisfaction surveys. In addition, the CNH Review 

Team also considers information obtained from the facility and/or 

VA Office of Inspector General 8 
Oversight of the Community Nursing Home Program VA North Texas Health Care System, Dallas, Texas

regional Ombudsman regarding the CNH facility. During annual 

reviews, and throughout the year as appropriate, the CNH Review 

Team and Oversight Committee review and discuss this information. 

Annual nursing facility evaluation forms and CNH quality indicator 

data will indicate consistent analysis of this information. When 

significant findings occur, the CNH Coordinator will immediately 

notify the Director, Chief of Staff and CNH Oversight Committee. 

These actions have been ongoing since the OIG conducted its site visit 

in May 2007. 

VA Office of Inspector General 9 
Oversight of the Community Nursing Home Program VA North Texas Health Care System, Dallas, Texas

Appendix C 

OIG Contact and Staff Acknowledgments 

OIG Contact Shirley Carlile, Healthcare Inspector 

Dallas Regional Office of Healthcare Inspections 

(214) 353-3337 

Acknowledgments Linda DeLong, Director 

Michael Shepherd, M.D., Medical Consultant 

VA Office of Inspector General 10 
Oversight of the Community Nursing Home Program VA North Texas Health Care System, Dallas, Texas

Appendix D 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Acting Director, Veterans Integrated Service Network 17 (10N17) 

Director, North Texas Veterans Health Care System (549/00) 

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: John Cornyn, Kay Bailey Hutchison 

U.S. House of Representatives: Joe Barton, Michael C. Burgess, Chet Edwards, Kay 

Granger, Ralph M. Hall, Jeb Hensarling, Eddie Bernice Johnson, Sam Johnson, Kenny 

Marchant, Pete Sessions 

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

VA Office of Inspector General 11