Department of Veterans Affairs

Office of Inspector General

Office of Healthcare Inspections

Report No. 08-02562-139

Combined Assessment Program 

Review of the 

Samuel S. Stratton VA Medical Center 

Albany, New York 

June 3, 2009

Washington, DC 20420 
Why We Did This Review 

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

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

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

of Healthcare Inspections and Investigations to provide collaborative assessments of 

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

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

convenient access to high quality medical services. 

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

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

to the OIG. 

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

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

To Report Suspected Wrongdoing in VA Programs and Operations 

Call the OIG Hotline – (800) 488-8244
Combined Assessment Program Review of the Samuel S. Stratton VA Medical Center, Albany, New York 

Table of Contents 

Page 

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

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

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

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

Organizational Strengths........................................................................................... 3 

Results ........................................................................................................................ 4 

Review Activities With Recommendations .............................................................. 4 

Quality Management Program........................................................................... 4 

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

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

Environment of Care.......................................................................................... 9 

Suicide Prevention Program.............................................................................. 11

Medication Management ................................................................................... 12

Review Activities Without Recommendations ......................................................... 13

Contracted/Agency Registered Nurses ............................................................. 13

Survey of Healthcare Experiences of Patients .................................................. 13

Appendixes

A. VISN Director Comments .................................................................................. 16

B. Medical Center Director Comments................................................................... 17

C. OIG Contact and Staff Acknowledgments ......................................................... 23

D. Report Distribution............................................................................................. 24

VA Office of Inspector General 
Combined Assessment Program Review of the Samuel S. Stratton VA Medical Center, Albany, New York 

Executive Summary 

Introduction During the week of April 6–10, 2009, the OIG conducted a 

Combined Assessment Program (CAP) review of the 

Samuel S. Stratton VA Medical Center (the medical center), 

Albany, NY. 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 for 

199 medical center employees. The medical center is part of 

Veterans Integrated Service Network (VISN) 2. 

Results of the 

Review 

This CAP review covered eight operational activities. We 

identified the following organizational strengths and reported 

accomplishments:

• Early Suicide Risk Detection. 

• New Employee Orientation Initiative. 

• Schwartz Center Rounds. 

We made recommendations in six of the activities reviewed; 

one recommendation was a repeat recommendation from 

the prior CAP review. For these activities, medical center 

managers needed to: 

• Collect and analyze provider performance data and use 

the information to support reprivileging decisions. 

• Appropriately identify and process institutional 

disclosures. 

• Monitor the implementation and efficacy of corrective 

actions identified through the root cause analysis (RCA) 

process and report the status of action items to an 

appropriate committee. 

• Develop a process to monitor the copying and pasting of 

text in the computerized patient record system (CPRS). 

• Use patient complaint data to improve patient services 

and ensure that data are presented to the committee 

responsible for QM/performance improvement (PI) 

activities. 

• Ensure that Emergency Department (ED) clinical staff 

obtain and maintain appropriate competencies. 

• Improve security in the ED. 

VA Office of Inspector General i
Combined Assessment Program Review of the Samuel S. Stratton VA Medical Center, Albany, New York 

• Protect patient privacy and secure medical information in 

the ED. 

• Improve the coordination of mental health (MH) services 

for community living center (CLC) patients. 

• Ensure that all staff who clean patient isolation rooms 

have documented training. 

• Enhance safety in the MH medication room. 

• Ensure compliance with Veterans Health Administration 

(VHA) regulations governing medical record 

documentation for patients deemed at high risk for 

suicide. 

• Ensure documentation of pain medication effectiveness 

within the required timeframe. 

The medical center complied with selected standards in the 

following two activities: 

• Contracted/Agency Registered Nurses (RNs). 

• Survey of Healthcare Experiences of Patients (SHEP). 

This report was prepared under the direction of 

Katherine Owens, Director, Bedford 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 15–21 for the full text of the Directors’ comments.) 

We will follow up on the planned actions until they are 

completed. 

 (original signed by:)

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

Assistant Inspector General for 

Healthcare Inspections 

VA Office of Inspector General ii
Combined Assessment Program Review of the Samuel S. Stratton VA Medical Center, Albany, New York 

VA Office of Inspector General 1 

Introduction 

Profile Organization. The medical center is a tertiary care facility 

located in Albany, NY, that provides a broad range of 

inpatient and outpatient health care services. Outpatient 

care is also provided at 11 community based outpatient 

clinics (CBOCs) in Plattsburgh, Malone, Elizabethtown, 

Glens Falls, Clifton Park, Fonda, Schenectady, Troy, 

Bainbridge, Catskill, and Kingston, NY. The medical center 

is part of VISN 2 and serves a veteran population of more 

than 130,300 in upstate New York. 

Programs. The medical center is a Clinical Referral Level 2 

facility. It provides comprehensive health care through 

primary care, acute care (medicine, surgery, and psychiatry), 

tertiary care, and long-term care services. Additionally, the 

medical center provides physical medicine and rehabilitation, 

neurology, oncology, dentistry, and geriatrics and extended 

care services. 

Affiliations and Research. The medical center is affiliated 

with Albany Medical College and provides training for more 

than 100 residents annually. It also provides training for 

other health care professions, such as dentistry, nursing, 

pharmacy, social work, psychology, and physical therapy. 

In fiscal year (FY) 2008, the medical center’s research 

program had 65 projects and a budget of approximately 

$1 million. Important areas of research included obstructive 

bladder dysfunction and clinical trials involving oncology, 

hematology, and cardiology. 

Resources. In FY 2008, the medical center’s medical care 

expenditures totaled approximately $153 million. FY 2008 

staffing was 1,146 full-time employee equivalents (FTE), 

including 84 physician and 334 nursing FTE. 

Workload. In FY 2008, the medical center treated more 

than 31,700 unique patients and provided almost 

24,000 acute inpatient days of care. In addition, the medical 

center provided over 15,000 inpatient days in its CLC.1

 The 

FY 2008 inpatient care workload (including CLC patients) 

totaled more than 2,600 discharges, and the average daily 

 

1

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

homelike environment to eligible veterans who require a nursing home level of care. 
Combined Assessment Program Review of the Samuel S. Stratton VA Medical Center, Albany, New York 

census was 107. Outpatient workload totaled over 

265,500 visits. 

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 eight activities: 

• Contracted/Agency RNs.

• Coordination of Care.

• Emergency/Urgent Care (E/UC) Operations.

• Environment of Care (EOC).

• Medication Management.

• QM Program.

• SHEP.

• Suicide Prevention Program.

The review covered medical center operations for FY 2008 

and quarter 1 of FY 2009 and was done in accordance with 

OIG standard operating procedures for CAP reviews. We 

also followed up on selected recommendations from our 

prior CAP review (Combined Assessment Program Review 

of the Samuel S. Stratton VA Medical Center, Albany, New 

VA Office of Inspector General 2 
Combined Assessment Program Review of the Samuel S. Stratton VA Medical Center, Albany, New York 

York, Report No. 06-01136-193, August 18, 2006). In that 

report, we identified improvement opportunities in EOC and 

QM. During the follow-up review, we found sufficient 

evidence that managers had implemented appropriate 

actions to address the identified EOC deficiencies, and we 

consider those issues closed. For QM, we determined that 

the recommendation for provider performance monitoring 

had not been completely addressed; therefore, we reissued 

a recommendation. 

During this review, we also presented fraud and integrity 

awareness briefings to 199 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 Strengths 

Early Suicide Risk 

Detection 

The medical center’s Suicide Prevention Coordinator (SPC) 

developed a database that allowed the analysis of multiple 

clinical and demographic data sets. As a result, clinical 

managers were able to identify a cohort of patients in the 

rural northern areas of New York who were at risk for suicide 

because of concomitant diagnoses of depression and 

substance abuse. Once these patients were identified, the 

goal was to engage them in MH treatment early on, monitor 

their progress in treatment, and strengthen coordination of 

care before the patients exhibited overt suicidal symptoms, 

such as ideation or attempt at self-harm. 

New Employee 

Orientation 

Initiative 

During FY 2008, the medical center moved away from the 

use of didactic learning techniques and initiated interactive, 

accelerated learning techniques to enhance new employee 

orientation. New employees teach themselves about key 

events in VA history by finding answers to questions through 

a series of informational posters placed at strategic points 

throughout the facility and discussing the information during 

orientation sessions. New employee satisfaction surveys 

consistently show that this interactive methodology is 

VA Office of Inspector General 3 
Combined Assessment Program Review of the Samuel S. Stratton VA Medical Center, Albany, New York 

VA Office of Inspector General 4 

effective, and the technique is scheduled to be expanded 

nationally. 

Schwartz Center 

Rounds 

The Schwartz Center is a nonprofit organization founded by 

Kenneth B. Schwartz, a cancer patient who desired to 

strengthen the relationship between patients and their 

caregivers. Schwartz Center Rounds is a multidisciplinary 

forum where caregivers discuss difficult emotional and social 

issues that arise in caring for very ill patients. The medical 

center instituted Schwartz Center Rounds in 2008 and 

included such topics as “Breaking Bad News” and “Putting 

Compassion to the Test – When you Don’t Want to Walk into 

the Room.” Attendance has averaged 70 participants per 

session. Through satisfaction survey data, staff reported 

that the discussions improved patient care and working 

relationships with colleagues. 

Results 

Review Activities With Recommendations 

Quality 

Management 

Program 

The purpose of this review was to evaluate whether: (a) the 

medical center had a comprehensive, effective QM program 

designed to monitor patient care activities and coordinate 

improvement efforts; (b) senior managers actively supported 

the program’s improvement activities and appropriately 

responded to QM results; and (c) the medical center was in 

compliance with VHA regulations, local policies, and 

appropriate accreditation standards. To evaluate QM 

processes, we interviewed senior managers and the QM 

Coordinator, and we reviewed the self-assessment regarding 

compliance with QM requirements. Additionally, we 

evaluated policies, PI data, and other relevant documents. 

The QM program was generally effective in its oversight of 

the quality of care provided at the medical center, and senior 

managers supported QM efforts through participation in and 

evaluation of PI initiatives and through allocation of 

resources to the program. However, we identified areas that 

needed improvement. 

Provider Performance Monitoring. VHA regulations2

 require 

that clinical managers develop plans for continuous 

performance monitoring of the medical staff. According to 

the requirements, performance data should be ongoing, 

 

2

 VHA Handbook 1100.19, Credentialing and Privileging, October 2, 2007. 
Combined Assessment Program Review of the Samuel S. Stratton VA Medical Center, Albany, New York 

VA Office of Inspector General 5 

include indicators for continuing qualifications and 

competencies, and be reviewed and considered during the 

reprivileging process. We reviewed credentialing and 

privileging (C&P) folders and corresponding PI data for 

22 providers reprivileged in the past 12 months and found 

that 10 (45 percent) had inadequate or no supporting QM/PI 

data for the privileges granted. This was a repeat finding 

from our previous CAP review. 

Institutional Disclosure. VHA regulations3 require that 

medical center managers disclose adverse events to 

patients. The regulations define two types of disclosures—

clinical and institutional.4 We reviewed the medical records 

of 18 patients who had clinical disclosures documented and 

determined that 4 (22 percent) of the cases met the criteria 

for an institutional disclosure. 

RCA Process. We found that RCA reviews were generally 

thorough; however, it was difficult to track whether managers 

implemented corrective actions identified through the RCA 

process and whether corrective actions were monitored for 

efficacy, as required by VHA regulations.5 At the time of the 

CAP review, the patient safety manager had primary 

responsibility for tracking implementation and monitoring 

corrective actions. However, the individual service 

managers who are responsible for implementation should be 

required to report the status of implementation and efficacy 

of the corrective actions to a senior-level committee. 

Medical Record Documentation. At the time of our review, 

there were no processes to monitor the copying and pasting 

of medical information in CPRS, as required by VHA 

regulations6

 and local policy. 

Patient Complaints. We found that the facility appropriately 

collected patient complaint data over time and identified 

improvement opportunities; however, we could not find 

evidence that managers implemented and monitored 

corrective actions, as required by VHA regulations.7

 

3

 VHA Directive 2008-002, Disclosure of Adverse Events to Patients, January 18, 2008. 4

 Clinical disclosure is an informal process to discuss harmful events with patients and/or families. Discussions are 

documented in the medical record. Institutional disclosure is a formal process used in cases of serious injury, death, 

or potential legal liability. It includes information about compensation and the procedures available to request it. 

5

 VHA Handbook 1050.01, VHA National Patient Safety Improvement Handbook, May 23, 2008. 6

 VHA Handbook 1907.01, Health Information Management and Health Records, August 25, 2006. 7

 VHA Handbook 1003.2, Service Recovery In The Veterans Health Administration, February 4, 2004; VHA 

Handbook 1003.4, VHA Patient Advocacy Program, September 2, 2005. 
Combined Assessment Program Review of the Samuel S. Stratton VA Medical Center, Albany, New York 

Additionally, we did not find that patient complaint data were 

presented to the committee responsible for QM/PI activities. 

Recommendation 1 We recommended that the VISN Director ensure that the 

Medical Center Director requires that clinical managers 

collect and analyze provider performance data and utilize the 

information to support reprivileging decisions. 

Recommendation 2 We recommended that the VISN Director ensure that the 

Medical Center Director requires that medical center 

managers appropriately identify and process institutional 

disclosures. 

Recommendation 3 We recommended that the VISN Director ensure that the 

Medical Center Director requires that responsible managers 

monitor the implementation and efficacy of corrective actions 

identified through the RCA process and report the status of 

action items to an appropriate committee. 

Recommendation 4 We recommended that the VISN Director ensure that the 

Medical Center Director requires that responsible managers 

develop a process to monitor the copying and pasting of text 

in CPRS. 

Recommendation 5 We recommended that the VISN Director ensure that the 

Medical Center Director requires that managers use patient 

complaint data to improve patient services and ensure that 

data are presented to the committee responsible for QM/PI 

activities. 

The VISN and Medical Center Directors agreed with the 

findings and recommendations. They reported that service 

line managers are completing physician professional practice 

evaluation folders, which will contain provider-specific data 

for VA and contract providers. This will be completed by 

July 2009. They also reported that managers developed 

processes to ensure that institutional disclosures are 

appropriately identified and acted upon and to ensure that 

responsible managers report the status of RCA action items 

to the appropriate committees. Additionally, they reported 

that they are implementing improved processes to monitor 

the importing/copying of text into CPRS and to monitor and 

trend patient complaint data. The implementation plans are 

acceptable, and we will follow up on the planned actions until 

they are completed. 

VA Office of Inspector General 6 
Combined Assessment Program Review of the Samuel S. Stratton VA Medical Center, Albany, New York 

VA Office of Inspector General 7 

Emergency/Urgent 

Care Operations 

The purposes of this review were to evaluate selected 

aspects of E/UC operations, such as clinical services, 

consults, inter-facility transfers, staffing, and staff 

competencies. We also inspected the physical environment 

for cleanliness, safety, and equipment maintenance. 

The medical center did not have a UC clinic but did have an 

ED that operated 7 days a week, 24 hours a day. We 

reviewed relevant VHA and medical center policies, and we 

interviewed the ED medical director and nurse manager. We 

also interviewed employees involved in managing transfers. 

Our review identified no issues with consults, transfers, 

staffing, and EOC. However, we identified the following 

areas that needed improvement. 

Staff Competencies. We reviewed the C&P files of three ED 

physicians and found that the physicians were privileged for 

airway management; however, there was no evidence to 

support that the physicians completed the necessary training 

and competence validation. VHA regulations8 require 

clinical managers to ensure the competence of clinicians 

who perform airway management outside of the operating 

room. At the time of our review, there was a plan in place to 

accomplish this, but it had not been implemented. 

Additionally, we reviewed the competency folders of three 

ED RNs. The medical center’s policy governing 

competencies requires that managers identify and verify the 

competencies necessary to perform safe patient care and 

that the competencies be role specific (for example, 

procedures or tasks performed in high-risk, problem-prone 

patient care areas). We found that service line managers 

responsible for the ED had not delineated specific mandatory 

competencies for ED nurses. 

Safety. We found five unsecured entrances to the ED that 

could potentially allow unauthorized access into the area. 

Police presence was not visible, and the main police office 

was not located in an area that provided optimal protection 

for ED staff and patients. 

Patient Privacy. VHA regulations9 require that medical 

centers protect patient privacy and secure medical 

information. Due to the physical design and space 

 

8

 VHA Directive 2005-031, Out-of-Operating Room Airway Management, August 8, 2005. 9

 VHA Handbook 1907.01. 
Combined Assessment Program Review of the Samuel S. Stratton VA Medical Center, Albany, New York 

limitations of the ED, there was a lack of auditory and visual 

patient privacy. Also, there were personnel located in the 

ED who were not essential to patient care. This could 

potentially further compromise patient privacy. Additionally, 

during our EOC rounds, we noted that there were two 

unattended computer monitors displaying patient 

information.

Recommendation 6 We recommended that the VISN Director ensure that the 

Medical Center Director requires that ED clinical staff obtain 

and maintain competencies appropriate to their ED duties. 

Recommendation 7 We recommended that the VISN Director ensure that the 

Medical Center Director requires that security in the ED be 

improved. 

Recommendation 8 We recommended that the VISN Director ensure that the 

Medical Center Director takes action to protect patient 

privacy and secure medical information in the ED. 

The VISN and Medical Center Directors agreed with the 

findings and recommendations. They reported that ED 

physicians will complete airway management competencies 

and that ED specific competencies for RNs will be identified. 

They also reported that there are plans to improve safety, 

patient privacy, and medical information security. The 

implementation plans are acceptable, and we will follow up 

on the planned actions until they are completed. 

Coordination of 

Care 

The purpose of this review was to evaluate whether the 

medical center’s inpatient consultations, intra-facility 

transfers, and discharges were coordinated appropriately 

over the continuum of care and whether the medical center 

was in compliance with VHA regulations, local policies, and 

accreditation standards. Coordinated consultations, 

transfers, and discharges are essential to integrated care 

processes that result in optimal patient care outcomes. 

We found that providers managed intra-facility transfers and 

patient discharges appropriately. Additionally, consult 

responses were timely; however, we identified one patient 

consult process that needed improvement. 

CLC MH Consults. We reviewed five inpatient MH consults 

for CLC patients. The consultants’ recommendations 

included transferring patients’ MH care to an outpatient MH 

VA Office of Inspector General 8 
Combined Assessment Program Review of the Samuel S. Stratton VA Medical Center, Albany, New York 

VA Office of Inspector General 9 

provider or to the MH provider in home-based primary care. 

However, we did not find documentation to support that 

continuity of MH care for these patients was provided. 

Recommendation 9 We recommended that the VISN Director ensure that the 

Medical Center Director requires that MH clinicians 

coordinate MH services for CLC patients. 

The VISN and Medical Center Directors agreed with the 

finding and recommendation. They reported that the medical 

center hired a psychologist who will be assigned full-time to 

the CLC. This will improve MH treatment and continuity and 

coordination of care in the CLC. The implementation plans 

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

until they are completed. 

Environment of 

Care

The purpose of this review was to determine whether the 

medical center maintained a safe and clean health care 

environment. VHA facilities are required to establish 

comprehensive EOC programs that fully meet VHA, 

Occupational Safety and Health Administration, and 

accreditation requirements. 

We inspected the following areas: (a) two medical/surgical 

units, (b) the intensive care unit, (c) the acute MH unit, 

(d) two CLC units, (e) the dialysis unit, (f) the substance 

abuse residential rehabilitation treatment unit, (g) the dental 

clinic, (h) the Nutrition and Food Service kitchen, (i) the 

geriatric primary care clinic, and (j) one CBOC. The areas 

we inspected were clean and well maintained, and nurse 

managers expressed satisfaction with the housekeeping staff 

assigned to their areas. Additionally, we determined that 

managers identified environmental hazards on the acute MH 

unit that potentially posed threats to patients. The medical 

center provided documentation of risk assessment and 

abatement tracking of safety issues previously identified on 

the unit, and we found that unit staff had completed suicide 

risk training. 

We also evaluated the IC program’s management of data 

and processes in which the data were used to improve 

performance and found the program satisfactory. However, 

we identified two areas that needed improvement. 

Training. Clostridium difficile (C. difficile)

10 is probably the 

 

10 C. difficile is a pathogen that causes gastrointestinal infections in humans. 
Combined Assessment Program Review of the Samuel S. Stratton VA Medical Center, Albany, New York 

VA Office of Inspector General 10 

most frequently identified cause of health care associated 

diarrhea and has been responsible for many large outbreaks 

in health care settings. The effects of C. difficile can range 

from diarrhea and abdominal discomfort to severe illness 

and death. Prevention focuses on accurate identification 

and isolation of affected patients, consistent hand hygiene 

practices, and environmental measures. Thorough cleaning 

of rooms that have housed patients with C. difficile diarrhea 

is an important intervention necessary to prevent 

transmission of the infection.11 

We reviewed the training records of 60 employees identified 

by management as qualified to clean patient isolation rooms. 

We found that 11 (18 percent) of the records lacked 

evidence of training specific to the containment of C. difficile. 

Staff Safety. The medication room on the acute MH unit has 

a window that opens out into the hall of the unit. Patients 

routinely come to the window to receive their medications. 

The location of the medication cart and other equipment in 

the room requires the nurse to turn his/her back to the 

window while he/she prepares medications. Since the nurse 

is not able to observe patients who may become agitated or 

aggressive while waiting for medications, this presents a 

potential safety risk. 

Recommendation 10 We recommended that the VISN Director ensure that the 

Medical Center Director requires that all staff designated as 

qualified to clean patient isolation rooms have documented 

training in the containment of C. difficile.

Recommendation 11 We recommended that the VISN Director ensure that the 

Medical Center Director enhances the safety of the MH 

medication room. 

The VISN and Medical Center Directors agreed with the 

findings and recommendations. They reported that 

C. difficile training has been completed and documented and 

that a duress alarm was installed in the MH medication room 

to improve safety. The corrective actions are acceptable, 

and we consider Recommendations 10 and 11 closed. 

Suicide Prevention The purpose of this review was to determine whether VHA 

health care facilities had implemented suicide prevention 

 

11 Under Secretary for Health Information Letter, IL 10-2005-018, Clostridium Difficile (C. difficile), 

September 8, 2005. 
Combined Assessment Program Review of the Samuel S. Stratton VA Medical Center, Albany, New York 

VA Office of Inspector General 11 

Program programs that were in compliance with VHA regulations.12

We assessed whether senior managers had appointed SPCs 

at facilities and very large CBOCs,13 and we evaluated 

whether SPCs fulfilled all required functions. Also, we 

verified whether medical records of patients determined to 

be at high risk for suicide contained Category II Patient 

Record Flags (PRFs),14 safety plans that addressed 

suicidality, and documented collaboration between MH 

providers and SPCs. 

We interviewed the SPC and reviewed pertinent policies. 

We found that the suicide prevention program was generally 

effective. The medical center had appointed an SPC who 

fulfilled all the required functions. The SPC had developed a 

tool to help staff effectively handle telephone calls from 

callers with suicidal ideation. However, we identified one 

area that needed improvement. 

Medical Record Documentation. We reviewed the medical 

records for 10 patients placed on the high-risk list. We found 

PRFs for all 10 patients. However, we found that two 

(20 percent) of the records did not show evidence of safety 

plans and that seven (70 percent) did not show clear 

evidence of collaboration between the SPC and MH 

providers. Although we were told that the SPC consults with 

MH providers regularly, this was not clearly documented in 

the records. 

Recommendation 12 We recommended that the VISN Director ensure that the 

Medical Center Director requires compliance with VHA 

regulations regarding documentation of safety plans and 

SPC and MH provider collaboration for patients deemed at 

high risk for suicide. 

The VISN and Medical Center Directors agreed with the 

findings and recommendations. They reported that the 

current list of high-risk patients will be reviewed to ensure 

that all patients have documented safety plans. Safety plan 

documentation for new patients added to the list will be 

monitored monthly. Additionally, managers will monitor 

documentation that supports the collaboration between the 

SPC and MH providers. The implementation plans are 

 

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

September 11, 2008. 

13 Very large CBOCs are defined as clinics with more than 10,000 unique patients enrolled. The medical center did 

not have a very large CBOC. 

14 A Category II PRF is an alert mechanism that is displayed prominently in medical records. 
Combined Assessment Program Review of the Samuel S. Stratton VA Medical Center, Albany, New York 

VA Office of Inspector General 12 

acceptable, and we will follow up on the planned actions until 

they are completed. 

Medication 

Management

The purpose of this review was to evaluate whether the 

medical center had adequate medication management 

processes to ensure safe ordering, dispensing, 

administering, and monitoring of medications. We reviewed 

medication management processes on inpatient and CLC 

units, and we interviewed nurse managers and other nursing 

staff. Additionally, we observed nurses administering 

medications, and we asked patients whether nurses scanned 

their wristbands prior to administering their medications. 

We found adequate management of medications brought 

into the medical center by patients or their families and 

determined that nurses scanned patients’ wristbands prior to 

medication administration. However, we identified one area 

that needed improvement. 

Pain Medication Reassessment. The medical center’s policy 

governing pain management requires that pain 

reassessments occur within 60 minutes after the 

administration of PRN15 pain medication. We reviewed 

92 administered doses of PRN pain medications for the 

period of January 18–24, 2009, and found that pain 

reassessments for 42 (46 percent) of the doses were not 

documented within the designated timeframe. 

Recommendation 13 We recommended that the VISN Director ensure that the 

Medical Center Director requires the documentation of PRN 

pain medication effectiveness within the required timeframe. 

The VISN and Medical Center Directors agreed with the 

finding and recommendation. They reported that the medical 

center changed the requirement for PRN effectiveness 

documentation to be consistent with community standards 

(4 hours). Nurse managers will monitor compliance monthly. 

The implementation plans are acceptable, and we will follow 

up on the planned actions until they are completed. 

Review Activities Without Recommendations 

Contracted/Agency 

Registered Nurses 

The purpose of this review was to evaluate whether RNs 

working in VHA facilities through contracts or temporary 

agencies met the same entry requirements as RNs hired as 

 

15 PRN is a Latin abbreviation [L pro re nata] meaning as needed or as the circumstances require. 
Combined Assessment Program Review of the Samuel S. Stratton VA Medical Center, Albany, New York 

employees of VHA facilities. We reviewed documents for 

several required components, including licensure, training, 

and competencies. Also, we reviewed folders for 

11 contracted/agency RNs who worked at the medical 

center. For all 11 RNs, documentation showed that 

managers had verified current licensure, life support 

certification, and competencies and that background checks 

had been completed. We also found documentation that 

10 (91 percent) of the 11 RNs had completed the required 

information security and privacy training. We made no 

recommendations. 

Survey of 

Healthcare 

Experiences of 

Patients 

The purpose of this review was to assess the extent that 

VHA health care facilities used quarterly or semi-annual 

SHEP results to improve patient care and services. VHA set 

performance measure goals for patients reporting overall 

satisfaction of “very good” or “excellent” at 76 percent for 

inpatients and 77 percent for outpatients. We reviewed 

SHEP scores for FYs 2007 and 2008. Figures 1 and 2 on 

the next page show the medical center’s patient satisfaction 

performance measure results for outpatients and inpatients, 

respectively. 

VA Office of Inspector General 13 
Combined Assessment Program Review of the Samuel S. Stratton VA Medical Center, Albany, New York 

Both outpatient and inpatient scores were above the target 

for 7 of 8 of the quarters reviewed. Managers analyzed 

SHEP data, identified service standards for further 

improvement, developed improvement strategies, and 

monitored the results of the strategies. Survey results and 

improvement strategies were distributed throughout the 

organization. We made no recommendations. 

VA Office of Inspector General 14 
Combined Assessment Program Review of the Samuel S. Stratton VA Medical Center, Albany, New York 

Appendix A 

VISN Director Comments 

VA Office of Inspector General 15 

Department of 

Veterans Affairs Memorandum 

Date: May 7, 2009 

From: Network Director, VA Healthcare Network Upstate New York 

(10N2)

Subject: Combined Assessment Program Review of the 

Samuel S. Stratton VA Medical Center, Albany, New York

To: Director, Bedford Office of Healthcare Inspections (54BN) 

Director, Management Review Service (10B5) 

I have reviewed the findings contained in the subject Combined 

Assessment Program Review conducted during the week of April 6, 2009. 

I concur with the facility action plans to resolve the identified findings. 

STEPHEN L. LEMONS, Ed.D., FACHE 
Combined Assessment Program Review of the Samuel S. Stratton VA Medical Center, Albany, New York 

Appendix B 

Medical Center Director Comments 

VA Office of Inspector General 16 

Department of 

Veterans Affairs Memorandum 

Date: May 7, 2009 

From: Director, Samuel S. Stratton VA Medical Center (528A8/00) 

Subject: Combined Assessment Program Review of the 

Samuel S. Stratton VA Medical Center, Albany, New York

To: Director Bedford Office of Healthcare Inspections (54BN) 

Director, Management Review Service (10B5) 

Our review of the findings contained in the subject Combined Assessment 

Program Review conducted during the week of April 6, 2009, has been 

completed. We concur with the findings noted therein, and submit for your 

review and approval our recommendations to resolve the identified 

findings. 

MARY-ELLEN PICHÉ, FACHE 

Director 

 
Combined Assessment Program Review of the Samuel S. Stratton VA Medical Center, Albany, New York 

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 clinical managers collect 

and analyze provider performance data and utilize the information to 

support reprivileging decisions. 

Concur 

Facility Response – By May 29, 2009 the Service Leads will have 

complete Physician Professional Practice Evaluation (PPPE) folders which 

include one full year of provider-specific quality data for all VA staff 

physicians. PPPE folders for contracted physicians will be complete by 

July 2009; all contract providers to be re-privileged prior to July will have 

complete PPPE folders to support reprivileging activities. 

Recommendation 2. We recommended that the VISN Director ensure 

that the Medical Center Director requires that medical center managers 

appropriately identify and process institutional disclosures. 

Concur 

Facility Response – All view alerts for disclosures will be reviewed by the 

Chief of Staff for appropriate follow through, with Risk Management 

tracking of all disclosures. 

Recommendation 3. We recommended that the VISN Director ensure 

that the Medical Center Director requires that responsible managers 

monitor the implementation and efficacy of corrective actions identified 

through the RCA process and report the status of action items to an 

appropriate committee. 

Concur 

Facility Response – A stand down for open and overdue actions is 

scheduled for May 11, 2009. The backlog will be resolved on this date. 

Management champions are held accountable for the follow-through and 

completion of RCA actions. Follow-through is monitored through the 

Patient Safety Committee, which reports quarterly on the status of actions 

to the Health Systems Committee. 

VA Office of Inspector General 17 
Combined Assessment Program Review of the Samuel S. Stratton VA Medical Center, Albany, New York 

VA Office of Inspector General 18 

Recommendation 4. We recommended that the VISN Director ensure 

that the Medical Center Director requires that responsible managers 

develop a process to monitor the copying and pasting of text in CPRS. 

Concur 

Facility Response – Subsequent to comprehensive retraining, all reviews 

conducted after May 8, 2009 will include an audit of the importing/copying 

of text in the electronic medical record. Results of these audits will be 

monitored through the Health Information Management System 

Committee, who will provide quarterly reports to the Executive Committee 

of the Medical Staff. 

Recommendation 5. We recommended that the VISN Director ensure 

that the Medical Center Director requires that managers use patient 

complaint data to improve patient services and ensure that data are 

presented to the committee responsible for QM/PI activities. 

Concur 

Facility Response – The Marketing and Communications Committee 

(MCC) is responsible for the identification and follow-through of actions 

based on analysis of patient satisfaction and complaint data. The Patient 

Advocate will include a separate analysis of patient complaint data and 

actions to the quarterly report to the Local Leadership Council through the 

Marketing and Communications Committee (MCC). Patient complaint 

action items will be included in quarterly reports of operations at the 

Network level. 

Recommendation 6. We recommended that the VISN Director ensure 

that the Medical Center Director requires that ED clinical staff obtain and 

maintain competencies appropriate to their ED duties. 

Concur 

Facility Response – A statement will be added to the facility competency 

policy in May 2009, requiring all work areas to have annual competency 

plans. ED specific competencies for nurses will be identified in May 2009, 

and the physician testing portion of competency for airway management 

will be completed by May 15, 2009. 

Recommendation 7. We recommended that the VISN Director ensure 

that the Medical Center Director requires that security in the ED be 

improved. 

Concur 
Combined Assessment Program Review of the Samuel S. Stratton VA Medical Center, Albany, New York 

Facility Response – The five ED access points were reviewed and 

prioritized for action based on location, use, accessibility, and risk level 

rating. The ambulance and main hallway entrances will be locked 24/7 

with swipe card access by September 2009; the critical path item for this 

change is lead time for the vendor to obtain parts. Procurement of the 

needed parts will be expedited. Regarding the remaining three access 

points, the doorway to the MEV building is already controlled as this is a 

24/7 secured area with access controlled at the check-in desk. Stairwells 

11 and 12 have very limited traffic and are primarily used by staff.

Police support and observation is strong based on the following:

• ED is equipped with duress alarms monitored by VA Police. 

• ED staff maintains a portable radio to contact VA Police as needed. 

• ED has two security cameras which are monitored by VA Police; one 

observes the AOD check in area (main hallway) and one the 

ambulance bay entrance. 

• VA Police maintain both administrative and operational areas within 

the left branch of the ED allowing for almost immediate response as 

needed. 

• VA Police make routine checks of the ED as part of daily patrol 

operations.

Recommendation 8. We recommended that the VISN Director ensure 

that the Medical Center Director takes action to protect patient privacy and 

secure medical information in the ED. 

Concur 

Facility Response – Pending completion of a planned construction project, 

reallocation of space within the existing ED will be completed in May 2009 

to address patient privacy and medical information security concerns. 

Modifications to, and realignment of, existing ED space will allow for 

additional treatment areas as well as a partitioned area for the physicians 

to work and meet with families. 

Recommendation 9. We recommended that the VISN Director ensure 

that the Medical Center Director requires that MH clinicians coordinate MH 

services for CLC patients. 

Concur 

Facility Response – A Gero-Psychologist for the CLC has been hired and 

is scheduled to start May 2009. This will improve CLC mental health 

treatment, continuity, and coordination of care. This clinician is one 

hundred percent assigned to the CLC, with twenty hours per week 

dedicated to being on the unit. 

VA Office of Inspector General 19 
Combined Assessment Program Review of the Samuel S. Stratton VA Medical Center, Albany, New York 

Recommendation 10. We recommended that the VISN Director ensure 

that the Medical Center Director requires that all staff designated as 

qualified to clean patient isolation rooms have documented training in the 

containment of C. difficile.

Concur. 

Facility Response – A new process was instituted in April 2009 for the 

documentation of FMS trainings. All trainings (formal and informal) are 

recorded in TEMPO and the descriptions of each training will be more 

specific to identify all the elements of the training. C. difficile training was 

completed in April 2009 for all staff who clean patient isolation rooms. 

Recommendation 11. We recommended that the VISN Director ensure 

that the Medical Center Director enhances the safety of the MH 

medication room. 

Concur. 

Facility Response – A duress button was installed in the medication room 

on the inpatient Mental Health unit on May 5, 2009. 

Recommendation 12. We recommended that the VISN Director ensure 

that the Medical Center Director requires compliance with VHA regulations 

regarding documentation of safety plans and SPC and MH provider 

collaboration for patients deemed at high risk for suicide. 

Concur. 

Facility Response – All patients on the High Risk List will have a Safety 

Plan upon discharge from inpatient acute psychiatry or at the next 

outpatient appointment. All current patients on the High Risk List will be 

reviewed and verified for a documented safety plan in CPRS by 

May 18, 2009. All Flag Management will document collaboration between 

the SPC and the Mental Health Provider. A monthly monitor was initiated 

on May 1, 2009, on all new patients to ensure completion of a safety plan. 

A monitor will be put in place in May 2009, verifying documentation of 

collaboration between the SPC and the Mental Health Providers on Flag 

Management, ensuring full implementation of the process. 

Recommendation 13. We recommended that the VISN Director ensure 

that the Medical Center Director requires the documentation of PRN pain 

medication effectiveness within the required timeframe. 

Concur. 

VA Office of Inspector General 20 
Combined Assessment Program Review of the Samuel S. Stratton VA Medical Center, Albany, New York 

VA Office of Inspector General 21 

Facility Response – Pain assessment and reassessment are based on the 

type of medication used and the patient’s response to pain. The facility 

pain policy has been changed to increase the timeframe for 

documentation of the pain reassessment to 4 hours. Both Joint 

Commission and OIG reviewers identified the 4-hour documentation time 

frame as community standard. Education of RN and LPN staff will be 

complete by May 29, 2009. Nurse Managers will monitor adherence to 

this policy on a monthly basis. Daily reporting of timely documentation is 

currently available to Nurse Managers each day and Monday morning for 

the weekends. 
Combined Assessment Program Review of the Samuel S. Stratton VA Medical Center, Albany, New York 

Appendix C 

VA Office of Inspector General 22 

OIG Contact and Staff Acknowledgments 

Contact Katherine Owens, MSN, Director 

Bedford Office of Healthcare Inspections 

(603) 222-5871/(781) 687-2317 

Contributors Annette Acosta, MN 

Jeanne Martin, Pharm.D. 

Glen Pickens, BSN 

Carol Torczon, MSN 

Gerard Poto, Office of Investigations 
Combined Assessment Program Review of the Samuel S. Stratton VA Medical Center, Albany, New York 

Appendix D 

VA Office of Inspector General 23 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VA Healthcare Network Upstate New York (10N2) 

Director, Samuel S. Stratton VA Medical Center (528A8/00) 

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: Kirsten E. Gillibrand, Charles E. Schumer 

U.S. House of Representatives: Paul D. Tonko 

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