Department of Veterans Affairs

Office of Inspector General

Office of Healthcare Inspections

Report No. 09-00732-124

Combined Assessment Program 

Review of the 

Jack C. Montgomery 

VA Medical Center 

Muskogee, Oklahoma 

May 12, 2009

Washington, DC 20420 
Why We Did This Review 

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

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

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

of Healthcare Inspections and Investigations to provide collaborative assessments of 

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

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

convenient access to high quality medical services. 

• Provide fraud and integrity awareness training to increase employee understanding of 

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

to the OIG. 

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

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

To Report Suspected Wrongdoing in VA Programs and Operations 

Call the OIG Hotline – (800) 488-8244
CAP Review of the Jack C. Montgomery VA Medical Center, Muskogee, Oklahoma 

Table of Contents 

Page 

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

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

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

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

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

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

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

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

Medication Management ................................................................................... 5

Environment of Care.......................................................................................... 6

Emergency/Urgent Care Operations ................................................................. 7

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

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

Suicide Prevention Program.............................................................................. 8

Survey of Healthcare Experiences of Patients .................................................. 9

Appendixes

A. VISN Director Comments .................................................................................. 11

B. Medical Center Director Comments................................................................... 12

C. OIG Contact and Staff Acknowledgments ......................................................... 15

D. Report Distribution............................................................................................. 16

VA Office of Inspector General 
CAP Review of the Jack C. Montgomery VA Medical Center, Muskogee, Oklahoma 

Executive Summary 

Introduction During the week of March 16–19, 2009, the OIG conducted a 

Combined Assessment Program (CAP) review of the 

Jack C. Montgomery VA Medical Center (the medical 

center), Muskogee, OK. The purpose of the review was to 

evaluate selected operations, focusing on patient care 

administration and quality management (QM). During the 

review, we also provided fraud and integrity awareness 

training to 527 medical center employees. The medical 

center is part of Veterans Integrated Service Network 

(VISN) 16. 

Results of the 

Review 

The CAP review covered seven operational activities. We 

identified the following organizational strength and reported 

accomplishment: 

• Dental Service Consultation Completion. 

We made recommendations in four of the activities reviewed. 

For these activities, the medical center needed to: 

• Complete initial peer reviews within the timeframe 

specified by Veterans Health Administration (VHA) policy. 

• Require that provider performance improvement (PI) data 

is collected, analyzed, reviewed, considered as part of the 

reprivileging process, and recorded in Professional 

Standards Board (PSB) minutes. 

• Update the local policy for emergency response and 

certification and ensure that designated staff maintain 

Basic Life Support (BLS) and/or Advanced Cardiac Life 

Support (ACLS) certification. 

• Document pain medication effectiveness in accordance 

with local policy. 

• Provide annual training on the environmental hazards that 

represent a threat to suicidal patients to all staff who work 

on the locked behavioral health unit and to members of the 

Multidisciplinary Safety Inspection Team. 

• Document that patients discharged from the emergency 

department (ED) receive a written copy of discharge 

instructions and verbalize understanding. 

The medical center complied with selected standards in the 

following three activities: 

VA Office of Inspector General i
CAP Review of the Jack C. Montgomery VA Medical Center, Muskogee, Oklahoma 

• Coordination of Care. 

• Suicide Prevention Program. 

• Survey of Healthcare Experiences of Patients (SHEP). 

This report was prepared under the direction of 

Linda G. DeLong, Director, Dallas Office of Healthcare 

Inspections. 

Comments The VISN and Medical Center Directors agreed with the CAP 

review findings and recommendations and provided 

acceptable improvement plans. (See Appendixes A and B, 

pages 11–14, for the full text of the Directors’ comments.) 

We will follow up on the planned actions until they are 

completed. 

 (original signed by:)

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

Assistant Inspector General for 

Healthcare Inspections 

VA Office of Inspector General ii
CAP Review of the Jack C. Montgomery VA Medical Center, Muskogee, Oklahoma 

VA Office of Inspector General 1 

Introduction 

Profile Organization. The medical center is a primary medical and 

surgical facility located in Muskogee, OK, that provides a 

broad range of inpatient and outpatient health care services. 

Outpatient care is also provided at two community based 

outpatient clinics (CBOCs) in Hartshorne and Tulsa, OK. 

The medical center is part of VISN 16 and serves a veteran 

population of more than 56,400 throughout eastern 

Oklahoma. 

Programs. The medical center provides medical, surgical, 

primary care, and mental health (MH) services. It has 

91 hospital beds. The medical center does not have a 

community living center.1

Affiliations and Research. The medical center is affiliated 

with Oklahoma State University’s College of Osteopathic 

Medicine and the University of Oklahoma’s College of 

Medicine and provides training for six medical residents per 

month. It also provides training for other disciplines, 

including physical therapy, nursing, radiation technology, 

phlebotomy, physician assistants, nurse practitioners, social 

work, optometry, and psychology. In fiscal year (FY) 2008, 

the medical center research program had four projects and a 

budget of $17,700 for staffing. An important area of 

research was heart disease. 

Resources. In FY 2008, medical care expenditures totaled 

$138 million. The FY 2009 medical care budget is 

$164 million. FY 2008 staffing was 963 full-time employee 

equivalents (FTE), including 65 physician and 207 nursing 

FTE. 

Workload. In FY 2008, the medical center treated 

32,817 unique patients and provided 23,877 inpatient days. 

The inpatient care workload totaled 4,041 discharges, and 

the average daily census was 65. Outpatient workload 

totaled 311,794 visits. 

 

1

 A community living center (formerly called a nursing home care unit) provides compassionate, person-centered 

care in a safe and homelike environment to eligible veterans who require a nursing home level of care. 
CAP Review of the Jack C. Montgomery VA Medical Center, Muskogee, Oklahoma 

Objectives and 

Scope 

Objectives. CAP reviews are one element of the OIG’s 

efforts to ensure that our Nation’s veterans receive high 

quality VA health care services. The objectives of the CAP 

review are to: 

• Conduct recurring evaluations of selected health care 

facility operations, focusing on patient care administration 

and QM.

• Provide fraud and integrity awareness training to increase 

employee understanding of the potential for program 

fraud and the requirement to refer suspected criminal 

activity to the OIG.

Scope. We reviewed selected clinical and administrative 

activities to evaluate the effectiveness of patient care 

administration and QM. Patient care administration is the 

process of planning and delivering patient care. QM is the 

process of monitoring the quality of care to identify and 

correct harmful and potentially harmful practices and 

conditions. 

In performing the review, we inspected work areas; 

interviewed managers and employees; and reviewed clinical 

and administrative records. The review covered the 

following seven activities: 

• Coordination of Care.

• Emergency/Urgent Care Operations.

• Environment of Care (EOC). 

• Medication Management.

• QM.

• SHEP. 

• Suicide Prevention Program. 

The review covered medical center operations for FY 2008 

and FY 2009 through March 16, 2009, and was done in 

accordance with OIG standard operating procedures for CAP 

reviews. We also followed up on select recommendations 

from our prior CAP review of the medical center (Combined 

Assessment Program Review of the Muskogee VA Medical 

Center, Muskogee, Oklahoma, Report No. 06-00896-212, 

September 18, 2006). The medical center had corrected all 

findings related to health care from the prior CAP review. 

VA Office of Inspector General 2 
CAP Review of the Jack C. Montgomery VA Medical Center, Muskogee, Oklahoma 

VA Office of Inspector General 3 

During this review, we also presented fraud and integrity 

awareness briefings for 527 employees. These briefings 

covered procedures for reporting suspected criminal activity 

to the OIG and included case-specific examples illustrating 

procurement fraud, conflicts of interest, and bribery. 

In this report, we make recommendations for improvement. 

Recommendations pertain to issues that are significant 

enough to be monitored by the OIG until corrective actions 

are implemented. Activities in the “Review Activities Without 

Recommendations” section have no reportable findings.

Organizational Strength 

Dental Service 

Consultation 

Completion

In FY 2007, dental consultation requests averaged 27 days 

for completion. A daily walk-in clinic was established in the 

1st quarter of FY 2008 for all inpatients and eligible 

outpatients with emergency dental treatment needs and for 

veterans with a compelling medical need, such as insulin 

dependent diabetes mellitus and pre-surgical evaluation. 

Since the clinic was established, dental consultation 

completion times have improved and now average 7 days.

Results 

Review Activities With Recommendations 

Quality 

Management 

The purpose of this review was to evaluate whether the 

medical center had a comprehensive QM program designed 

to monitor patient care quality and whether senior managers 

actively supported the program’s activities. We evaluated 

policies, PI data, and other relevant documents. We 

interviewed appropriate senior managers and the QM 

Coordinator. 

The medical center’s QM program was generally effective, 

and senior managers supported the program through 

participation in and evaluation of PI initiatives and through 

allocation of resources to the program. However, we 

identified the following areas that needed improvement. 

Peer Review Process. Once the need for a peer review is 

determined, VHA policy2

 requires that initial reviews are 

completed within 45 days. In FY 2008, 8 (14 percent) of 

58 peer reviews exceeded 45 days for the initial review. For 

 

2

 VHA Directive 2008-004, Peer Review for Quality Management, January 28, 2008. 
CAP Review of the Jack C. Montgomery VA Medical Center, Muskogee, Oklahoma 

VA Office of Inspector General 4 

FY 2009 through March 16, 2009, 4 (8 percent) of 52 peer 

reviews exceeded 45 days for the initial review. The peer 

review process needed to be improved to ensure timely 

completion of initial reviews. 

Provider Performance Monitoring. VHA regulations3 and 

Joint Commission (JC) standards require that clinical 

managers develop plans for continuous performance 

monitoring of the medical staff. According to the 

requirements, performance data should be ongoing, include 

indicators for continuing qualifications and competencies, be 

reviewed and considered during the reprivileging process, 

and be recorded in PSB minutes. At the time of our site visit, 

plans for ongoing physician competency monitoring had 

been developed. We reviewed credentialing and privileging 

(C&P) folders and corresponding PI data for 17 providers 

reprivileged in the past 12 months. We found that 

15 (88 percent) of 17 providers had inadequate data 

recorded in PSB minutes to support the privileges granted. 

Resuscitation and Outcomes. Local policy requires the 

medical center to have a mechanism in place to consistently 

review staff compliance with current BLS and/or ACLS 

certification. We reviewed documentation for staff 

required to have current BLS certification and found that 

10 (2 percent) of 535 certifications had expired. Also, we 

identified that 1 (1 percent) of 115 staff required to have 

ACLS certification had an expired certification. Additionally, 

review of the local policy for cardiopulmonary resuscitation 

and response to medical emergency situations identified the 

need for the policy to be updated to place an emphasis on 

airway management. 

Recommendation 1 We recommended that the VISN Director ensure that the 

Medical Center Director requires that initial peer reviews are 

completed within the timeframe specified by VHA policy. 

The VISN and Medical Center Directors concurred with the 

findings and recommendation. If the initial peer review is not 

completed within 21 days, the Risk Manager will ensure that 

a message is sent to the appropriate individuals to alert them 

of the timeframe. Additionally, the timeframe for completion 

of the final review has been shortened to ensure compliance 

with VHA policy. The corrective action is acceptable, and we 

consider this recommendation closed. 

 3

 VHA Handbook 1100.19, Credentialing and Privileging, October 2, 2007. 
CAP Review of the Jack C. Montgomery VA Medical Center, Muskogee, Oklahoma 

VA Office of Inspector General 5 

Recommendation 2 We recommended that the VISN Director ensure that the 

Medical Center Director requires that provider PI data be 

collected, analyzed, reviewed, considered as part of the 

reprivileging process, and recorded in PSB minutes. 

The VISN and Medical Center Directors concurred with the 

findings and recommendation. The PSB minutes format has 

been changed to incorporate specific PI data. The 

improvement plan is acceptable, and we will follow up on the 

action to ensure completion. 

Recommendation 3 We recommended that the VISN Director ensure that the 

Medical Center Director requires that the local policy for 

emergency response and certification is updated and that 

designated staff maintain current BLS and/or ACLS 

certification. 

The VISN and Medical Center Directors concurred with the 

findings and recommendation. Local policy will be updated 

to include the process for tracking BLS and/or ACLS 

certification. Reminders will be sent to employees and 

service chiefs prior to the expiration of certification. Service 

chiefs will monitor certification and will report monthly to the 

Executive Committee of the Medical Staff (ECMS). The 

improvement plans are acceptable, and we will follow up on 

the completion of the planned actions. 

Medication 

Management 

The purpose of this review was to evaluate whether VHA 

facilities had adequate medication management practices. A 

safe medication management system includes medication 

ordering, administering, and monitoring. 

We reviewed selected medication management processes in 

the intensive care, MH, and rehabilitation units and in two 

medicine units. We found appropriate use of patient 

armbands to correctly identify patients prior to medication 

administration. However, we identified one area that needed 

improvement. 

Pain Medication Effectiveness. VHA regulations4

 and local 

policy require that the effects of pain medication are 

monitored. Local policy requires the use of a pain scale for 

documentation of a patient’s initial pain level and for 

follow-up of pain medication effectiveness. We found that all 

133 administered doses of pain medication reviewed had an 

 

4

 VHA Directive 2003-021, Pain Management, May 2, 2003. 
CAP Review of the Jack C. Montgomery VA Medical Center, Muskogee, Oklahoma 

VA Office of Inspector General 6 

initial pain score documented. However, for 38 (29 percent) 

of the 133 doses, documentation for follow-up of pain 

medication effectiveness did not include a pain score. 

Recommendation 4 We recommended that the VISN Director ensure that the 

Medical Center Director requires clinicians to document pain 

medication effectiveness in accordance with local policy. 

The VISN and Medical Center Directors concurred with the 

finding and recommendation. The medical center developed 

a PowerPoint presentation that includes examples of how to 

document pain medication effectiveness. The presentation 

was provided to inpatient nurses. Pain medication 

effectiveness will be monitored and reported to the ECMS. 

The corrective action is acceptable, and we consider this 

recommendation closed. 

Environment of 

Care 

The purpose of this review was to determine if the medical 

center maintained a safe and clean health care environment. 

The medical center is required to provide a comprehensive 

EOC program that fully meets VA National Center for Patient 

Safety, Occupational Safety and Health Administration, and 

JC standards. The infection control (IC) program was 

evaluated to determine compliance with VHA directives 

based on the management of data collected and processes 

in which the data were used to improve performance. 

We inspected the intensive care, medical and surgical, 

locked behavioral health, and rehabilitation units. We also 

inspected the ED and the dental clinic. The medical center 

maintained a clean and safe environment. The IC program 

monitored and reported data to clinicians for implementation 

of quality improvements. However, we identified one area 

that needed improvement. 

Locked Behavioral Health Unit. All staff who work on the 

locked behavioral health unit and members of the 

Multidisciplinary Safety Inspection Team should receive the 

required annual training on environmental hazards that 

represent a threat to suicidal patients.5 Initial training was 

provided at new employee orientation; however, specific 

ongoing annual training was not provided. 

 

5

 Deputy Under Secretary for Health for Operations and Management, memorandum to VISN Directors, 

August 27, 2007. 
CAP Review of the Jack C. Montgomery VA Medical Center, Muskogee, Oklahoma 

Recommendation 5 We recommended that the VISN Director ensure that the 

Medical Center Director requires that all staff who work on 

the locked behavioral health unit and members of the 

Multidisciplinary Safety Inspection Team receive annual 

training on the environmental hazards that represent a threat 

to suicidal patients. 

The VISN and Medical Center Directors concurred with the 

findings and recommendation. The Suicide Prevention 

Coordinator (SPC) provided training to members of the 

Multidisciplinary Safety Inspection Team and to locked 

behavioral health unit staff. Training will continue to be 

provided annually. The improvement plan is acceptable, and 

we will follow up on the completion of the planned actions. 

Emergency/Urgent 

Care Operations 

The purpose of this review was to evaluate selected aspects 

of care and operations in VHA EDs and/or urgent care 

clinics, such as hours of operation, clinical services, 

consults, inter-facility transfers, staffing, and staff 

competencies. In addition, we inspected the ED and triage 

environments for cleanliness and safety. 

We interviewed program managers, transfer coordinators, 

and physicians. We reviewed documents, including local 

policies, C&P folders, competency files, medical records of 

patients seen in the ED, and certified time schedules. 

The ED is open 24 hours a day, 7 days a week. Emergency 

services provided are within the facility’s patient care 

capabilities, and a policy is in place for managing patients 

whose care exceeds the medical center’s capability. Our 

review demonstrated that clinical services, consults, staffing, 

and nursing competencies were documented appropriately. 

However, we identified one area that needed improvement. 

Discharge Instructions. We reviewed the medical records of 

six MH patients discharged from the ED. We found no 

documentation that these patients received written discharge 

instructions and verbalized understanding of the instructions. 

The program manager informed us that a template was used 

to document discharge instructions; however, the template 

did not include whether a patient received a written copy of 

the instructions and verbalized understanding. Management 

updated the template while we were onsite. 

Recommendation 6 We recommended that the VISN Director ensure that the 

Medical Center Director requires ED clinicians to document 

VA Office of Inspector General 7 
CAP Review of the Jack C. Montgomery VA Medical Center, Muskogee, Oklahoma 

VA Office of Inspector General 8 

that patients receive a written copy of discharge instructions 

and verbalize understanding. 

The VISN and Medical Center Directors concurred with the 

findings and recommendation. Nurses are giving patients 

discharge instructions and will document patient 

understanding in the electronic medical record. The 

corrective action is acceptable, and we consider this 

recommendation closed. 

Review Activities Without Recommendations 

Coordination of 

Care 

The purpose of this review was to evaluate whether VHA 

facilities had adequate processes to ensure coordination of 

care across the continuum of patient services. We reviewed 

three aspects of care: (1) patient consults, (2) patient 

intra-facility transfers, and (3) patient discharges. We found 

that providers managed all three aspects appropriately. We 

made no recommendations. 

Suicide Prevention 

Program 

The purpose of this review was to determine whether VHA 

health care facilities had implemented a suicide prevention 

program that was in compliance with VHA regulations. We 

assessed whether senior managers had appointed SPCs at 

facilities and very large CBOCs,6

 and we evaluated whether 

SPCs fulfilled all required functions. Also, we verified 

whether medical records of patients determined to be at high 

risk for suicide contained Category II Patient Record Flags,7

documented safety plans that addressed suicidality, and 

documented collaboration between MH providers and SPCs. 

We interviewed the SPCs and MH providers. We reviewed 

pertinent policies and the medical records of 10 patients 

determined to be at risk for suicide. We found that 

documentation was complete in all 10 medical records. 

Senior managers had appropriately appointed SPCs, and the 

SPCs fulfilled the required functions. We made no 

recommendations. 

 

6

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

7

 A Category II Patient Record Flag is an alert mechanism that is displayed prominently in electronic medical 

records. 
CAP Review of the Jack C. Montgomery VA Medical Center, Muskogee, Oklahoma 

Survey of 

Healthcare 

Experiences of 

Patients 

The purpose of this review was to assess the extent that 

VHA facilities use quarterly survey results of patients’ health 

care experiences with VHA to improve patient care, 

treatment, and services. The Performance Analysis Center 

for Excellence of the Office of Quality and Performance 

within VHA is the analytical, methodological, and reporting 

staff for SHEP. VHA set performance measure (PM) target 

results for patients reporting overall satisfaction of “very 

good” or “excellent” at 76 percent for inpatients and 

77 percent for outpatients. Facilities are expected to 

address areas that fall below target scores. Figures 1 and 2 

(below and on the next page) show the medical center’s 

SHEP PM results for inpatients and outpatients, respectively. 

60

65

70

75

80

85

90

95

100

Qtr 4 (FY 06) Qtr 1 (FY 07) Qtr 2 (FY 07) Qtr 3 (FY 07) Qtr 4 (FY 07) Qtr 1 (FY 08) Qtr 2 (FY 08) Qtr 3 (FY 08)

Percent Reporting Overall Quality as Very Good or Excellent

Quarter Reported

Facility

VISN

National

JACK C. MONTGOMERY VA MEDICAL 

CENTER

INPATIENT OVERALL QUALITY

BY QUARTER

Meets 

Target

Figure 1:

VA Office of Inspector General 9 
CAP Review of the Jack C. Montgomery VA Medical Center, Muskogee, Oklahoma 

60

65

70

75

80

85

90

95

100

Qtr 4 (FY 06) Qtr 1 (FY 07) Qtr 2 (FY 07) Qtr 3 (FY 07) Qtr 4 (FY 07) Qtr 1 (FY 08) Qtr 2 (FY 08) Qtr 3 (FY 08)

Percent Reporting Overall Quality as Very Good or Excellent

Quarter Reported

Facility

VISN

National

JACK C. MONTGOMERY VA MEDICAL 

CENTER

OUTPATIENT OVERALL QUALITY

BY QUARTER

Figure 2:

Meets 

Target

The medical center did not meet the established target for 

2 of the last 8 quarters of available data for inpatient 

satisfaction and 5 of the last 8 quarters of available data for 

outpatient satisfaction. However, managers had identified 

opportunities for improvement based on the SHEP survey 

scores and had developed action plans targeting specific 

services and departments. The action plans were 

implemented, and there was evidence of ongoing activities 

and evaluation for effectiveness. Therefore, we made no 

recommendations. 

VA Office of Inspector General 10 
CAP Review of the Jack C. Montgomery VA Medical Center, Muskogee, Oklahoma 

Appendix A 

VISN Director Comments 

VA Office of Inspector General 11 

Department of 

Veterans Affairs Memorandum 

Date: April 16, 2009 

From: Director, South Central VA Health Care Network (10N16) 

Subject: Combined Assessment Program Review of the 

Jack C. Montgomery VA Medical Center, Muskogee, 

Oklahoma 

To: Director, Dallas Healthcare Inspections Division (54DA) 

Director, Management Review Service (10B5) 

1. The CAP Report for Jack C. Montgomery VAMC has been reviewed. 

Hospital leadership is in concurrence with the report, and 

recommendations have been addressed with corrective action. 

2. If you have further questions, please contact Mary Jones, VISN 16 

Health System Specialist, at 601-364-7871. 

 (original signed by:) 

George H. Gray, Jr. 
CAP Review of the Jack C. Montgomery VA Medical Center, Muskogee, Oklahoma 

Appendix B 

Medical Center Director Comments 

VA Office of Inspector General 12 

Department of 

Veterans Affairs Memorandum 

Date: April 2, 2009 

From: Director, Jack C. Montgomery VAMC, Muskogee, OK (623/00) 

Subject: Combined Assessment Program Review of the 

Jack C. Montgomery VA Medical Center, Muskogee, 

Oklahoma 

To: Network Director, VISN 16 

We concur with the recommendations. 

 (original signed by:) 

ADAM C. WALMUS 
CAP Review of the Jack C. Montgomery VA Medical Center, Muskogee, Oklahoma 

Comments to Office of Inspector General’s Report 

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

recommendations in the Office of Inspector General report: 

OIG Recommendations

Recommendation 1. We recommended that the VISN Director ensure 

that the Medical Center Director requires that initial peer reviews are 

completed within the timeframe specified by VHA policy. 

Concur Target Completion Date: April 3, 2009 

Action Plan: Peer Review process is monitored closely by the Risk 

Manager regarding the initial peer review 45-day timeframe and the 

120-day timeframe to Peer Review Committee. If the initial Peer Review 

is not completed within 21 days, an Outlook message will be sent to the 

appropriate provider responsible for the initial Peer Review, Service Chief, 

Chief of Staff, Quality Manager, and the Medical Center Director to alert 

everyone involved of the timeframe. If the Peer Review has not been 

presented at the Peer Review Committee within 75 days, an Outlook 

message will be sent to Service Chief, Chief of Staff, Quality Manager, 

and the Medical Center Director to alert everyone involved of the 

timeframe. The timeframe has been shortened to ensure compliance with 

the VHA policy. Recommend that Recommendation 1 be closed. 

Recommendation 2. We recommended that the VISN Director ensure 

that the Medical Center Director requires that provider PI data be 

collected, analyzed, reviewed, considered as part of the reprivileging 

process, and recorded in PSB minutes. 

Concur Target Completion Date: April 13, 2009 

Action Plan: PSB minutes format has been changed to reflect specific PI 

data. Recommend that Recommendation 2 be closed. 

Recommendation 3. We recommended that the VISN Director ensure 

that the Medical Center Director requires that the local policy for 

emergency response and certification is updated and that designated staff 

maintain current BLS and/or ACLS certification. 

Concur Target Completion Date: May 31, 2009 

Action Plan: Local policy will be updated to reflect the process for tracking 

BLS and/or ACLS certification. Reminders are sent out to employees and 

VA Office of Inspector General 13 
CAP Review of the Jack C. Montgomery VA Medical Center, Muskogee, Oklahoma 

VA Office of Inspector General 14 

Service Chiefs prior to the expiration. BLS and/or ACLS certification will 

be monitored by Service Chiefs and reported monthly at ECMS. 

Recommendation 4. We recommended that the VISN Director ensure 

that the Medical Center Director requires clinicians to document pain 

medication effectiveness in accordance with local policy. 

Concur Target Completion Date: May 31, 2009 

Action Plan: A PowerPoint presentation was developed with appropriate 

examples of how to document pain medication effectiveness utilizing a 

pain score. This PowerPoint presentation was provided to the inpatient 

RNs and LPNs. Pain medication effectiveness will be monitored and 

reported to ECMS. 

Recommendation 5. We recommended that the VISN Director ensure 

that the Medical Center Director requires that all staff who work on the 

locked behavioral health unit and members of the Multidisciplinary Safety 

Inspection Team receive annual training on the environmental hazards 

that represent a threat to suicidal patients. 

Concur Target Completion Date: May 31, 2009 

Action Plan: The Suicide Prevention Coordinator presented a PowerPoint 

on the environmental hazards that represent a threat to suicidal patients to 

the Multidisciplinary Safety Inspection Team and the locked behavioral 

health unit staff. A presentation on environmental hazards that represent 

a threat to suicidal patients will be presented to new staff on the 

Multidisciplinary Safety Inspection Team and to new staff on the locked 

behavioral health unit and annually. 

Recommendation 6. We recommended that the VISN Director ensure 

that the Medical Center Director requires ED clinicians to document that 

patients receive a written copy of discharge instructions and verbalize 

understanding. 

Concur Target Completion Date: April 13, 2009 

Action Plan: The patients are given discharge instructions by the nurse 

and documenting the patient’s understanding. This will then be 

documented in the electronic medical record in the nursing discharge 

note. Recommend that Recommendation 6 be closed. 
CAP Review of the Jack C. Montgomery VA Medical Center, Muskogee, Oklahoma 

Appendix C 

VA Office of Inspector General 15 

OIG Contact and Staff Acknowledgments 

Contact Linda DeLong, Director 

Dallas Office of Healthcare Inspections 

(214) 253-3331 

Contributors Shirley Carlile, Team Leader 

Cathleen King 

Karen Moore 

Wilma Reyes 

Jacki Billings, Office of Investigations 
CAP Review of the Jack C. Montgomery VA Medical Center, Muskogee, Oklahoma 

Appendix D 

VA Office of Inspector General 16 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, South Central VA Health Care Network (10N16) 

Director, Jack C. Montgomery VA Medical Center (623/00) 

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: Tom Coburn, James M. Inhofe 

U.S. House of Representatives: Dan Boren, Tom Cole, Mary Fallin, Frank Lucas, 

John Sullivan 

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