Department of Veterans Affairs

Office of Inspector General

Office of Healthcare Inspections

Report No. 08-03088-138

Combined Assessment Program 

Review of the 

G. V. (Sonny) Montgomery 

VA Medical Center 

Jackson, Mississippi 

June 2, 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 G. V. (Sonny) Montgomery VA Medical Center, Jackson, Mississippi 

Table of Contents 

Page 

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

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

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

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

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

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

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

Suicide Prevention Program.............................................................................. 3

Environment of Care.......................................................................................... 4

Quality Management ......................................................................................... 6

Medication Management ................................................................................... 8

Review Activities Without Recommendations ......................................................... 9

Contract/Agency Registered Nurses ................................................................. 9

Coordination of Care ......................................................................................... 9

Emergency/Urgent Care Operations ................................................................. 10

Patient Satisfaction............................................................................................ 11

Appendixes

A. VISN Director Comments .................................................................................. 14

B. Medical Center Director Comments................................................................... 15

C. OIG Contact and Staff Acknowledgments ......................................................... 18

D. Report Distribution............................................................................................. 19

VA Office of Inspector General 
CAP Review of the G. V. (Sonny) Montgomery VA Medical Center, Jackson, Mississippi 

Executive Summary 

Introduction During the week of January 26–30, 2009, the OIG conducted 

a Combined Assessment Program (CAP) review of the 

G. V. (Sonny) Montgomery VA Medical Center (the medical 

center), Jackson, MS. 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 252 medical center employees. The medical 

center is part of Veterans Integrated Service Network 

(VISN) 16. 

Results of the 

Review 

The CAP review covered eight operational activities. We 

identified the following organizational strength and reported 

accomplishment: 

• Patient Safety Program. 

We made recommendations in four of the activities reviewed. 

For these activities, the medical center needed to ensure 

that: 

• Safety plans are completed for patients deemed at high 

risk for suicide. 

• The air ventilation outlets in the community living center 

(CLC) and on one acute inpatient unit (4CS) are cleaned 

according to the standard operating procedure. 

• The cleanliness of the dialysis unit is maintained. 

• The security of the medication room on the 

post-anesthesia care unit (PACU) is maintained. 

• Peer reviews are completed in a timely manner. 

• The Peer Review Committee (PRC) fully documents 

discussions in committee minutes. 

• Mechanisms are in place to adequately evaluate and 

disclose adverse events. 

• The effectiveness of pain medication is documented in the 

electronic medical record within the medical center’s 

required timeframe. 

VA Office of Inspector General i
CAP Review of the G. V. (Sonny) Montgomery VA Medical Center, Jackson, Mississippi 

The medical center complied with selected standards in the 

following four activities: 

• Contract/Agency Registered Nurses (RNs). 

• Coordination of Care (COC). 

• Emergency/Urgent Care Operations. 

• Patient Satisfaction. 

This report was prepared under the direction of 

Christa Sisterhen, Director, St. Petersburg 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 14–17, 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 G. V. (Sonny) Montgomery VA Medical Center, Jackson, Mississippi 

VA Office of Inspector General 1 

Introduction 

Profile Organization. The medical center is a tertiary care facility 

located in Jackson, MS, that provides a broad range of 

inpatient and outpatient health care services. Outpatient care 

is also provided at seven community based outpatient clinics 

(CBOCs) in Kosciusko, Greenville, Hattiesburg, Natchez, 

Meadville, Columbus, and Meridian, MS. The medical center 

is part of VISN 16 and serves a veteran population of about 

132,000 throughout 19 counties in Mississippi and Arkansas. 

Programs. The medical center provides medical, surgical, 

primary care, mental health (MH), long-term care, and 

rehabilitation services. It has 128 hospital beds and 

120 CLC1 beds. 

Affiliations and Research. The medical center is affiliated 

with 25 colleges, universities, and institutions. It supports 

training for 338 medical residents and for various other 

disciplines. In fiscal year (FY) 2008, the medical center 

research program had 82 projects and a budget of $1 million. 

Important areas of research included Alzheimer’s disease, 

schizophrenia, and hypertension. 

Resources. In FY 2008, medical care expenditures totaled 

$276 million. FY 2008 staffing was 1,864 full-time employee 

equivalents (FTE), including 99 physician and 593 nursing 

FTE. 

Workload. In FY 2008, the medical center treated 

44,976 unique patients and provided 34,858 inpatient days in 

the hospital and 37,312 inpatient days in the CLC. The 

inpatient care workload totaled 5,981 discharges, and the 

average daily census, including CLC patients, was 

197. Outpatient workload totaled 459,786 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.

 

1

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

home-like environment to eligible veterans who require a nursing home level of care. 
CAP Review of the G. V. (Sonny) Montgomery VA Medical Center, Jackson, Mississippi 

• 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: 

• Contract/Agency RNs.

• COC.

• Emergency/Urgent Care Operations.

• Environment of Care (EOC).

• Medication Management.

• Patient Satisfaction.

• QM.

• Suicide Prevention Program.

The review covered medical center operations for FY 2007, 

FY 2008, and FY 2009 through January 23, 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 of the medical 

center (Combined Assessment Program Review of the 

G.V. (Sonny) Montgomery VA Medical Center, Jackson, 

Mississippi, Report No. 06-01520-211, September 15, 2006). 

The medical center had corrected all findings related to 

health care from our prior CAP review. 

During this review, we also presented fraud and integrity 

awareness briefings to 252 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. 

VA Office of Inspector General 2 
CAP Review of the G. V. (Sonny) Montgomery VA Medical Center, Jackson, Mississippi 

VA Office of Inspector General 3 

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 findings that required 

corrective action.

Organizational Strength 

Patient Safety 

Program 

The National Center for Patient Safety (NCPS) recently 

instituted a new program called the “Cornerstone” program. 

Its purpose is to enhance the root cause analysis (RCA) 

process. The “Cornerstone” program recognizes patient 

safety staff at the medical center level by rewarding VA 

medical centers for timeliness in completion of the RCA 

process. Medical centers are required to complete eight 

RCAs per year. This medical center received the “bronze” 

award from the NCPS for FY 2008 for completing 20 RCAs 

within the required 45-day timeframe.

Results 

Review Activities With Recommendations 

Suicide Prevention 

Program 

The purpose of this review was to determine whether the 

medical center had implemented a suicide prevention 

program that was in compliance with Veterans Health 

Administration (VHA) regulations. We assessed whether 

senior managers had appointed a Suicide Prevention 

Coordinator (SPC) at the medical center and at any very 

large CBOCs,2 and we evaluated whether the SPC 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),3

 documented 

safety plans that addressed suicidality, and documented 

collaboration between MH providers and the SPC. 

We interviewed the medical center SPC, and we reviewed 

pertinent policies and the medical records of 12 patients 

determined to be at risk for suicide. We found that the 

suicide prevention program was generally effective; however, 

we identified one area in need of improvement. 

 

2

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

3

 A Category II PRF is an alert mechanism that is displayed prominently in medical records. 
CAP Review of the G. V. (Sonny) Montgomery VA Medical Center, Jackson, Mississippi 

VA Office of Inspector General 4 

Medical Record Review. VHA regulations4 require that all 

medical records of patients at high risk for suicide have a 

Category II PRF and a safety plan and show evidence of 

collaboration between the SPC and MH providers. We found 

that the required PRFs were present in all 12 of the records 

reviewed and that all contained documented evidence of 

collaboration between the SPC and MH providers. However, 

only 4 (33 percent) of the 12 records contained evidence of a 

safety plan. 

Recommendation 1 We recommended that the VISN Director ensure that the 

Medical Center Director requires compliance with VHA 

regulations regarding documentation of safety plans for 

patients deemed at high risk for suicide. 

The VISN and Medical Center Directors agreed with the 

findings and recommendation and reported that a process 

has been implemented to ensure that all patients on the 

high-risk list have safety plans. The SPC will track 

documentation and share this information with leadership 

during morning reports. The improvement plan is acceptable, 

and we will follow up on the completion of the planned 

actions. 

Environment of 

Care 

The purpose of this review was to determine if the medical 

center maintained a safe and clean health care environment. 

VHA medical centers are required to provide a 

comprehensive EOC program that fully meets VHA, NCPS, 

Occupational Safety and Health Administration, and Joint 

Commission (JC) standards. 

We inspected the acute inpatient units on 2A, 4CN, and 4CS; 

the medical intensive care unit; the surgical intensive care 

unit (SICU); and the PACU. We also inspected the locked 

MH unit, the CLC, the dialysis unit, the emergency 

department (ED), and the primary care clinics. We found that 

the medical center was generally clean and well maintained 

and had corrected the EOC findings from our prior CAP 

review. 

The infection control program monitored exposures and 

reported data to clinicians for implementation of quality 

improvements. Also, we found that the majority of the 

hazards on the “Mental Health Environment of Care 

 4

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

September 11, 2008. 
CAP Review of the G. V. (Sonny) Montgomery VA Medical Center, Jackson, Mississippi 

VA Office of Inspector General 5 

Checklist”5 had been abated on the locked MH unit, as 

required by VHA. However, we identified deficiencies related 

to environmental cleanliness, security of medications, and 

patient privacy. 

We found that video monitor screens used for patient 

observation at the SICU nursing station could be viewed by 

anyone on the unit, including visitors. JC standards require 

hospitals to respect each patient’s need for privacy. 

Managers installed privacy screens on the monitors while we 

were onsite; therefore, we made no recommendation for this 

finding. 

Environmental Cleanliness. During environmental rounds, 

we found dust in air ventilation outlets in several bathrooms 

in the CLC and on one acute inpatient unit (4CS). The 

medical center had not followed their standard operating 

procedure for cleaning the air ventilation outlets. The air 

ventilation outlets in the CLC were cleaned while we were 

onsite, and medical center managers provided an action plan 

to clean all the air ventilation outlets on the acute inpatient 

units. 

The dialysis unit preparation room was not clean; there were 

visible stains and spills on the floor, on trashcans, and in 

sinks. We were told that Environmental Management 

Service (EMS) cleaned the unit during the night shift; 

however, they did not routinely clean it during the day. The 

unit was thoroughly cleaned while we were onsite, and 

managers presented us with an action plan that included 

daily cleaning by EMS during the day shift and additional 

support whenever needed. 

Security of Medications. We found the door to the 

medication room on the PACU unlocked and propped open. 

A nurse told us that the door was kept open for immediate 

access to medications during an emergency. JC standards 

require that all medications be secured to prevent access by 

unauthorized individuals. The door was secured while we 

were onsite, and managers presented us with an action plan 

to ensure that the security of medications on the PACU is 

maintained. 

 5

 A tool used for the purpose of assessing environmental risks and eliminating factors that could contribute to 

attempted suicide or suicide of a patient or harm to a staff member. 
CAP Review of the G. V. (Sonny) Montgomery VA Medical Center, Jackson, Mississippi 

Recommendation 2 We recommended that the VISN Director ensure that the 

Medical Center Director requires that the air ventilation 

outlets in the CLC and on acute inpatient unit 4CS are 

cleaned according to the standard operating procedure. 

The VISN and Medical Center Directors agreed with the 

findings and recommendation. The air ventilation outlets 

were cleaned the day of the finding, and a schedule has been 

developed for cleaning all air ventilation outlets areas in the 

medical center. The improvement plan is acceptable, and we 

will follow up on the completion of the planned actions. 

Recommendation 3 We recommended that the VISN Director ensure that the 

Medical Center Director requires that the cleanliness of the 

dialysis unit is maintained. 

The VISN and Medical Center Directors agreed with the 

findings and recommendation and reported that scheduled 

cleaning will take place on a daily basis and as needed. The 

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

completion of the planned actions. 

Recommendation 4 We recommended that the VISN Director ensure that the 

Medical Center Director requires that the security of the 

medication room on the PACU is maintained. 

The VISN and Medical Center Directors agreed with the 

findings and recommendation and reported that PACU 

medication room security will be monitored daily by the 

nursing supervisor. The improvement plan is acceptable, 

and we will follow up on the completion of the planned 

actions. 

Quality 

Management 

The purpose of this review was to determine 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 

QM efforts and appropriately responded to QM results; and 

(c) the medical center was in compliance with VHA directives, 

appropriate accreditation standards, and Federal and local 

regulations. We interviewed the medical center’s senior 

management team and QM personnel. We reviewed plans, 

policies, and other relevant QM documents. 

The QM program was generally effective in providing 

oversight of the medical center’s quality of care, and senior 

managers supported the program. Appropriate review 

VA Office of Inspector General 6 
CAP Review of the G. V. (Sonny) Montgomery VA Medical Center, Jackson, Mississippi 

VA Office of Inspector General 7 

structures were in place for 13 of the 15 program activities 

reviewed. However, we identified two areas that needed 

improvement. 

Peer Review. We found that the medical center’s PRC did 

not comply with certain aspects of VHA policy.6 We 

evaluated peer review activities conducted during 

FY 2008 and identified the following issues: 

• The PRC did not complete all peer reviews within the 

required timeframes. We noted that 27 (20 percent) of 

the 133 peer reviews did not meet the initial 45-day 

deadline and that 21 (16 percent) did not meet the 

120-day completion deadline. 

• PRC minutes did not contain complete documentation of 

formal discussions of the cases under review, the issues 

under consideration, or the process by which members 

reached consensus regarding the quality of care. 

Adverse Event Disclosure. The medical center did not 

comply with all elements of VHA policy7

 for disclosure of 

adverse events to patients and/or their families within 

required timeframes. Clinical disclosure is an informal 

process which must occur within 24 hours of provider 

awareness of the event. Institutional disclosure is a more 

formal process which must occur within 72 hours of provider 

awareness of the event and is used in cases of serious injury, 

death, or potential legal liability. Institutional disclosure 

includes documentation of an apology and compensation 

information. 

The medical center identified 23 events that required 

disclosure in the 1-year period ending in November 2008. 

We found that 14 (61 percent) of the 23 events were 

disclosed within the required timeframes. Also, while onsite, 

we discovered two cases that had not been identified by the 

medical center for consideration of disclosure. We met with 

the Chief of Staff who agreed that clinical disclosure was 

appropriate for these two cases. 

Recommendation 5 We recommended that the VISN Director ensure that the 

Medical Center Director requires timely completion of peer 

reviews. 

 

6

 VHA Directive 2008-004, Peer Review for Quality Management, January 28, 2008. 7

 VHA Directive 2008-002, Disclosure of Adverse Events, January 18, 2008. 
CAP Review of the G. V. (Sonny) Montgomery VA Medical Center, Jackson, Mississippi 

VA Office of Inspector General 8 

The VISN and Medical Center Directors agreed with the 

findings and recommendation and reported that a plan has 

been put in place to ensure completion of peer reviews within 

the required timeframes. The improvement plan is 

acceptable, and we will follow up on the completion of the 

planned actions. 

Recommendation 6 We recommended that the VISN Director ensure that the 

Medical Center Director requires full documentation of PRC 

discussions in committee minutes. 

The VISN and Medical Center Directors agreed with the 

findings and recommendation and reported that PRC minutes 

will now contain full documentation of discussions. The 

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

completion of the planned actions. 

Recommendation 7 We recommended that the VISN Director ensure that the 

Medical Center Director requires that mechanisms are in 

place to adequately evaluate and disclose adverse events in 

accordance with VHA policy. 

The VISN and Medical Center Directors agreed with the 

findings and recommendation and reported that disclosures 

are now being performed for all known complications. The 

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

completion of the planned actions. 

Medication 

Management

The purpose of this review was to evaluate whether the 

medical center had safe medication management practices 

that complied with medical center policy. Medication 

management includes ordering, administering, and 

monitoring medications. 

We reviewed selected medication management processes on 

the acute inpatient medical and surgical units, on the 

telemetry unit, and in the CLC. We randomly selected 

20 patients’ medical records for documentation of PRN8 pain 

medication effectiveness. Our selection included five 

patients from each of four different inpatient units. 

We found adequate management of medications brought into 

the medical center by patients or their families and 

appropriate use of patient armbands to correctly identify 

 

8

 PRN medications are administered on an “as needed” basis. 
CAP Review of the G. V. (Sonny) Montgomery VA Medical Center, Jackson, Mississippi 

patients prior to medication administration. However, we 

identified the following area that needed improvement. 

Documentation of PRN Effectiveness. The effectiveness of 

PRN pain medications was not consistently documented in 

accordance with medical center policy. We reviewed 

57 doses of pain medications and found that 18 (32 percent) 

doses did not have medication effectiveness documented 

within 4 hours of administration and that 3 (5 percent) doses 

had no documentation of medication effectiveness. 

Recommendation 8 We recommended that the VISN Director ensure that the 

Medical Center Director requires that the effectiveness of 

PRN pain medication is documented in the electronic medical 

record within the medical center’s required timeframe. 

The VISN and Medical Center Directors agreed with the 

findings and recommendation and reported that actions will 

be taken to ensure appropriate documentation of the 

effectiveness of PRN medications. The improvement plan is 

acceptable, and we will follow up on the completion of the 

planned actions. 

Review Activities Without Recommendations 

Contract/Agency 

Registered Nurses 

The purpose of this review was to evaluate whether RNs 

working in the medical center through contracts or temporary 

staffing agencies met the same requirements as RNs hired 

as part of the medical center’s staff. We reviewed eight 

contract RN files for several required components, including 

licensure, training, and VHA and medical center specific 

competencies. 

We found that the medical center had appropriate processes 

in place for hiring and evaluating contract staff and followed 

them consistently. However, we found discrepancies 

between two medical center policies and the orientation 

checklist for documents required for employee files. We 

suggested that the discrepancies between the policies and 

the checklist be reconciled so that all contain an accurate list 

of required documentation. Medical center managers revised 

the policies and the checklist while we were onsite; therefore, 

we made no recommendations. 

Coordination of 

Care 

The purpose of this review was to evaluate whether inpatient 

consultations, intra-facility (unit-to-unit) transfers, and 

discharges were coordinated appropriately over the 

VA Office of Inspector General 9 
CAP Review of the G. V. (Sonny) Montgomery VA Medical Center, Jackson, Mississippi 

continuum of care and met medical center, VHA, and JC 

requirements. Coordinated consultations, transfers, and 

discharges are essential to an integrated, ongoing care 

process and optimal patient outcomes. 

We reviewed inpatient consultations and found that 

10 (83 percent) of the 12 were completed within the 24 hours 

required by medical center policy. Also, we reviewed the 

medical records of patients who were transferred 

between inpatient units. In 11 (92 percent) of the 12 records 

reviewed, we found consistent and timely documentation of 

nurse-to-nurse communication from the sending unit to 

receiving unit, and 10 (83 percent) of the 12 records 

showed appropriate physician-to-physician communication. 

Additionally, we reviewed 12 medical records of discharged 

patients and found documentation that all patients received 

and understood the written discharge instructions. We made 

no recommendations. 

Emergency/Urgent 

Care Operations 

The purpose of this review was to evaluate selected aspects 

of care and operations in the medical center’s ED, including 

clinical services, consultations, inter-facility transfers, staffing, 

and staff competencies. We also assessed the ED’s physical 

environment and equipment maintenance. 

We interviewed program managers and transfer coordinators. 

Also, we reviewed competency files; credentialing and 

privileging folders; and the medical records of patients who 

were seen in the ED and subsequently transferred to other 

medical facilities, admitted to inpatient units within the 

medical center, or discharged home. 

The ED is open 24 hours per day, 7 days per week, as 

required for ED designation. The ED environment and 

design are efficient, effective, and maintain patient privacy. 

Emergency services provided are within the facility’s patient 

care capabilities. In addition, we found appropriate 

Memorandums of Understanding with local private facilities 

for managing patients whose care may exceed the medical 

center’s capability. 

Our review showed that clinical services; consultations; 

staffing; and medical record admission, discharge, and 

transfer documentation were appropriate. Electronic medical 

record documentation of patient care was easily identifiable, 

multidisciplinary, and complete. 

VA Office of Inspector General 10 
CAP Review of the G. V. (Sonny) Montgomery VA Medical Center, Jackson, Mississippi 

We found that ED nursing staff annual competency 

assessments did not include high-risk, low-volume skills, 

including use of pediatric emergency equipment and 

medications. Because the ED is equipped with emergency 

pediatric equipment and medications, appropriate ED nursing 

staff must be evaluated annually to ensure that they maintain 

the necessary skills to use them safely and effectively. While 

we were onsite, the unit-specific annual competency skills 

evaluation list was modified to include these skills; therefore, 

we made no recommendations. 

Patient Satisfaction The Survey of Healthcare Experiences of Patients (SHEP) is 

aimed at capturing patient perceptions of care in 12 service 

areas, including access to care, coordination of care, and 

courtesy. VHA relies on the Office of Quality and 

Performance’s analysis of the survey data to improve the 

quality of care delivered to patients. The purpose of this 

review was to assess the extent that the medical center used 

SHEP data to improve patient care, treatment, and services. 

VHA’s Executive Career Field Performance Plan states that 

at least 76 percent of inpatients discharged during a specified 

date range and 77 percent of outpatients treated will report 

the overall quality of their experiences as “very good” or 

“excellent.” Facilities are expected to address areas in which 

they are underperforming. 

The graphs on the next page show the medical center’s 

performance in relation to national and VISN performance. 

Figure 1 shows the medical center’s SHEP performance 

measure (PM) results for inpatients. Figure 2 shows the 

medical center’s SHEP PM results for outpatients. 

VA Office of Inspector General 11 
CAP Review of the G. V. (Sonny) Montgomery VA Medical Center, Jackson, Mississippi 

50

55

60

65

70

75

80

85

90

95

100

Qtr 3 (FY 06) 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)

Quarter Reported

Percent Reporting Overall Quality as Very Good or Excellent

Facility

VISN

National

G. V. (SONNY) MONTGOMERY VA MEDICAL CENTER

INPATIENT OVERALL QUALITY

BY QUARTER

Meets 

Target

Figure 1:

40

45

50

55

60

65

70

75

80

85

90

95

100

Qtr 3 (FY 06) 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)

Quarter Reported

Percent Reporting Overall Quality as Very Good or Excellent

Facility

VISN

National

G. V. (SONNY) MONTGOMERY VA MEDICAL CENTER

OUTPATIENT OVERALL QUALITY

BY QUARTER

Figure 2:

Meets 

Target

VA Office of Inspector General 12 
CAP Review of the G. V. (Sonny) Montgomery VA Medical Center, Jackson, Mississippi 

VA Office of Inspector General 13 

The medical center’s inpatient overall SHEP scores from the 

3rd quarter of FY 2006 through the 2nd quarter of FY 2008 

met or exceeded the target in 5 of the 8 quarters. Outpatient 

scores also met or exceeded the target in 5 of the 8 quarters. 

The medical center had an active Customer Service Council 

(CSC), which included the Patient Advocate Program and 

the Patient Ombudsman Program. The CSC analyzed 

SHEP data, internal “quick card” survey comments, and data 

from an additional survey the medical center purchases that 

provides more immediate feedback to identify areas in need 

of improvement. 

All survey results are communicated monthly to appropriate 

service managers. Two processes worthy of special note 

are (1) weekly peer reviews conducted by the patient 

advocate to ensure that patient complaint data are 

accurately entered into the Patient Advocate Tracking 

System and (2) a template note entered in the electronic 

medical record to document results of the follow-up call to 

discharged patients by the patient ombudsman. Because 

patient satisfaction was high and the actions of the CSC 

appeared to be effective, we made no recommendations. 
CAP Review of the G. V. (Sonny) Montgomery VA Medical Center, Jackson, Mississippi 

Appendix A 

VISN Director Comments 

VA Office of Inspector General 14 

Department of 

Veterans Affairs Memorandum 

Date: April 8, 2009 

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

Subject: Combined Assessment Program Review of the 

G. V. (Sonny) Montgomery VA Medical Center, Jackson, 

Mississippi 

To: Director, St. Petersburg Regional Office of Healthcare 

Inspections (54SP) 

Director, Management Review Service (10B5) 

I have reviewed the response to the subject CAP and concur. 

 (original signed by:) 

George H. Gray, Jr. 
CAP Review of the G. V. (Sonny) Montgomery VA Medical Center, Jackson, Mississippi 

Appendix B 

Medical Center Director Comments 

VA Office of Inspector General 15 

Department of 

Veterans Affairs Memorandum 

Date: April 3, 2009 

From: Director, G. V. (Sonny) Montgomery VA Medical Center 

(586/00) 

Subject: Combined Assessment Program Review of the 

G. V. (Sonny) Montgomery VA Medical Center, Jackson, 

Mississippi 

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

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 compliance with VHA regulations 

regarding documentation of safety plans for patients deemed at high risk 

for suicide. 

Concur Completion Date: 2/27/09 

Action Taken: A process has been implemented to ensure that all 

patents on the high risk list receive safety plans. Both the Suicide 

Prevention Coordinator and Suicide Case Manager conduct at a minimum, 

weekly chart audits to assess documentation compliance, including the 

completion of safety plans. This information is also reported to the Chief, 

Mental Health and the Chief of Staff (COS). Deficiencies noted are 

directly addressed with the appropriate provider for correction. 

Compliance is now at 100%. 

A data dashboard that includes documentation of safety plans for all 

patients on the high risk list has also been developed for tracking by the 

Suicide Prevention Coordinator. This information is shared with facility 

Leadership during morning report. 
CAP Review of the G. V. (Sonny) Montgomery VA Medical Center, Jackson, Mississippi 

VA Office of Inspector General 16 

Recommendation 2. We recommended that the VISN Director ensure 

that the Medical Center Director requires that the air ventilation outlets in 

the CLC and on acute inpatient unit 4CS are cleaned according to the 

standard operating procedure. 

Concur: Completion Date: 2/04/09 

Action Taken: The dirty air vents identified in the NHCU and 4CS were 

cleaned the same day of the finding. EMS has developed a schedule for 

cleaning air vents in all areas of the facility. This process will be verified 

and documented by visual supervisory oversight weekly and written 

supervisory oversight on a monthly basis. 

Recommendation 3. We recommended that the VISN Director ensure 

that the Medical Center Director requires that the cleanliness of the 

dialysis unit is maintained. 

Concur: Completion Date: 1/28/09 

Action Taken: In addition to the end of day cleaning, EMS has scheduled 

Housekeeping to clean Hemodialysis (including the Prep Room) during 

the day shift at 1:30 p.m. Nursing staff in the Hemodialysis unit have 

been instructed to call EMS at any time during the workday when 

additional cleaning is needed. 

Recommendation 4. We recommended that the VISN Director ensure 

that the Medical Center Director requires that the security of the 

medication room on the PACU is maintained. 

Concur: Completion Date: 1/28/09 

Action Taken: The door was closed and locked at the time of the finding. 

Nursing Service has counseled the responsible Nursing personnel on this 

issue. Security of the medication room in PACU has been added to the 

Nursing Supervisor daily rounds. Random audits have confirmed that the 

door is being kept closed and locked at all times. 

Recommendation 5. We recommended that the VISN Director ensure 

that the Medical Center Director requires timely completion of peer 

reviews. 

Concur: Completion Date: 1/28/09 

Action Taken: Reviews continue to be tracked for compliance with the 

mandated timeframes by the Peer Review Coordinator. The majority of 

deficiencies were due to external reviews, especially specialty reviews. 
CAP Review of the G. V. (Sonny) Montgomery VA Medical Center, Jackson, Mississippi 

VA Office of Inspector General 17 

The Peer Review Coordinator has broadened the list of reviewer facilities 

to request external review assignments. If no response is received from 

an outside facility within 2 days, VISN 16 Health System Specialist is 

contacted for assistance. VHA is currently in the process of securing 

contracts with outside facilities to conduct external peer reviews. 

Recommendation 6. We recommended that the VISN Director ensure 

that the Medical Center Director requires full documentation of PRC 

discussions in committee minutes. 

Concur Completion Date: 2/06/09 

Action Taken: CAP Review recommendations have been incorporated 

into the PRC meeting minutes. More detail is now being included in the 

minutes to fully document the reasons when changes are made in the 

determination of levels. 

Recommendation 7. We recommended that the VISN Director ensure 

that the Medical Center Director requires that mechanisms are in place to 

adequately evaluate and disclose adverse events in accordance with VHA 

policy. 

Concur Completion Date: 1/28/09 

Action Taken: Prior practice was based on guidance from Regional 

Counsel. Clarification has now also been obtained from VACO regarding 

disclosure of complications. Based on this clarification, disclosures are 

now being performed on all known complications.

Recommendation 8. We recommended that the VISN Director ensure 

that the Medical Center Director requires that the effectiveness of PRN 

pain medication is documented in the electronic medical record within the 

medical center’s required timeframe. 

Concur Target Completion Date: April 2009 

Action Taken: The PRN effectiveness data will be reported monthly in 

the Medical Records Committee meeting. Data will be reviewed by the 

Committee, and forwarded to Leadership through the Executive 

Committee of the Medical Staff (ECMS), Quality Executive Board (QEB), 

and Governance. The data will also be provided to the Head Nurses for 

action, if needed. 
CAP Review of the G. V. (Sonny) Montgomery VA Medical Center, Jackson, Mississippi 

Appendix C 

VA Office of Inspector General 18 

OIG Contact and Staff Acknowledgments 

Contact Christa Sisterhen, Director 

St. Petersburg Office of Healthcare Inspections 

(727) 395-2419 

Contributors David Griffith, CAP Coordinator 

Idell L. Graham 

Deborah Howard 

Annette Robinson 

Carol Torczon 

John Ramsey, Office of Investigations 
CAP Review of the G. V. (Sonny) Montgomery VA Medical Center, Jackson, Mississippi 

Appendix D 

VA Office of Inspector General 19 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

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

Director, G. V. (Sonny) Montgomery VA Medical Center (586/00) 

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: Thad Cochran, Roger F. Wicker 

U.S. House of Representatives: Gregg Harper 

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