Department of Veterans Affairs 

Office of Inspector General 

Office of Healthcare Inspections
 

Report No.10-02987-78 

Combined Assessment Program
 

Review of the
 

Hunter Holmes McGuire
 

VA Medical Center
 

Richmond, Virginia
 

January 31, 2011
 

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 crime awareness briefings 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 

Telephone: 1-800-488-8244 

E-Mail: vaoighotline@va.gov 

(Hotline Information: http://www.va.gov/oig/contacts/hotline.asp) 
CAP Review of the Hunter Holmes McGuire VA Medical Center, Richmond, VA 

Glossary 

C&P credentialing and privileging 

CAP Combined Assessment Program 

CBOC community based outpatient clinic 

CHF congestive heart failure 

CLC community living center 

COC coordination of care 

EOC environment of care 

facility Hunter Holmes McGuire VA Medical Center 

FPPE Focused Professional Practice Evaluation 

FTE full-time employee equivalents 

FY fiscal year 

ICU intensive care unit 

JC Joint Commission 

MDRO multidrug-resistant organism 

MEC Medical Executive Committee 

OIG Office of Inspector General 

OSHA Occupational Safety and Health Administration 

PI patient information 

PPE personal protective equipment 

PRRTP Psychosocial Residential Rehabilitation Treatment 

Program 

QM quality management 

RCA root cause analysis 

SOPs standard operating procedures 

SPD Supply, Processing, and Distribution 

VHA Veterans Health Administration 

VISN Veterans Integrated Service Network 

VA OIG Office of Healthcare Inspections 
CAP Review of the Hunter Holmes McGuire VA Medical Center, Richmond, VA 

Table of Contents 

Page
 

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

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

Objectives ............................................................................................................... 1
 

Scope...................................................................................................................... 1
 

Reported Accomplishments...................................................................................... 2
 

Results ........................................................................................................................ 2
 

Review Activities With Recommendations .............................................................. 2
 

EOC................................................................................................................... 2
 

Management of MDRO...................................................................................... 3
 

Management of Test Results............................................................................. 4
 

Physician C&P................................................................................................... 4
 

Review Activities Without Recommendations ......................................................... 5
 

COC .................................................................................................................. 5
 

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

QM..................................................................................................................... 5
 

Comments................................................................................................................... 6
 

Appendixes 

A. Facility Profile .................................................................................................... 7
 

B. Follow-Up on Previous Recommendations........................................................ 8
 

C. VHA Satisfaction Surveys and Hospital Outcome of Care Measures................ 11
 

D. VISN Director Comments .................................................................................. 13
 

E. Facility Director Comments ............................................................................... 14
 

F. OIG Contact and Staff Acknowledgments ......................................................... 17
 

G. Report Distribution ............................................................................................ 18
 

VA OIG Office of Healthcare Inspections 
Executive Summary: Combined Assessment Program 

Review of the Hunter Holmes McGuire VA Medical Center, 

Richmond, VA 

Review Purpose: The purpose was 

to evaluate selected activities, focusing 

on patient care administration and 

quality management, and to provide 

crime awareness training. We 

conducted the review the week of 

October 18, 2010. 

Review Results: The review covered 

seven activities. We made no 

recommendations in the following three 

activities: 

 Coordination of Care 

 Medication Management 

 Quality Management 

The facility’s reported accomplishments 

were winning the Carey Award for 

performance achievement, making 

community living center improvements, 

and improving patient flow and access. 

Recommendations: We made 

recommendations in the following four 

activities: 

Environment of Care: Ensure all 

designated staff complete annual N95 

respirator fit testing, and document the 

training. Strengthen processes to 

ensure confidential patient information is 

secured. 

Management of Multidrug-Resistant 

Organisms: Ensure that patients 

infected or colonized with 

multidrug-resistant organisms and their 

families receive infection prevention 

strategies education and that the 

education is documented. 

Management of Test Results: 

Consistently communicate normal test 

results within the specified timeframe. 

Physician Credentialing and Privileging: 

Ensure that privileges appropriately 

indicate the setting where they may be 

practiced and that results of Focused 

Professional Practice Evaluation are 

reported to the Medical Executive 

Committee. 

Comments 

The Veterans Integrated Service 

Network and Facility Directors agreed 

with the Combined Assessment 

Program review findings and 

recommendations and provided 

acceptable improvement plans. 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 OIG Office of Healthcare Inspections i 
CAP Review of the Hunter Holmes McGuire VA Medical Center, Richmond, VA 

Objectives and Scope 

Objectives
 

Scope
 

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 crime awareness briefings to increase employee 

understanding of the potential for program fraud and the 

requirement to refer suspected criminal activity to the 

OIG. 

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 selected areas, 

interviewed managers and employees, and reviewed clinical 

and administrative records. The review covered the 

following seven activities: 

	 COC 

	 EOC 

	 Management of MDRO 

	 Management of Test Results 

	 Medication Management 

	 Physician C&P 

	 QM 

The review covered facility operations for FY 2010 and 

FY 2011 through October 18, 2010, and was done in 

accordance with OIG SOPs for CAP reviews. We also 

followed up on selected recommendations from our prior 

CAP review of the facility (Combined Assessment 

Program Review of the Hunter Holmes McGuire VA Medical 

Center, Richmond, Virginia, Report No. 07-01753-07, 

VA OIG Office of Healthcare Inspections 1 
CAP Review of the Hunter Holmes McGuire VA Medical Center, Richmond, VA 

October 16, 2007). The facility had corrected all findings. 

(See Appendix B for further details.) 

During this review, we also presented crime awareness 

briefings for 274 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. 

Reported Accomplishments 

Carey Achievement	 The facility received the 2010 Robert W. Carey Award for 

Award Performance Achievement for efforts made to improve the 

capabilities of the facility and the effectiveness of patient 

care and for the creation of a learning organization. By 

focusing on process improvement and performance 

excellence, the facility improved its Carey application score 

by 125 points from 2009 to 2010. 

CLC Improvements	 The facility embraced cultural transformation in the CLC by 

adding a mural and an electric fireplace in the dining room. 

In the day room, staff created a 1950s soda shop complete 

with a red and white soda counter and a jukebox, and they 

hold ice cream socials every Friday. In addition, staff added 

a dementia engagement nook where residents can safely 

engage in a variety of supervised activities. 

Patient Flow and	 Participation in the Facility Flow Collaborative is evidenced 

Access by strong core metrics. Building on this foundation, the 

facility expanded surgical briefings for all surgical 

sub-specialties to include a huddle with SPD personnel 

2 days prior to a scheduled procedure. This has enhanced 

efficiency and safety and reduced surgical cancellations. 

Results 

Review Activities With Recommendations 

EOC	 The purpose of this review was to determine whether the 

facility maintained a safe and clean health care environment 

in accordance with applicable requirements. 

We inspected the emergency department; primary care 

clinics; behavioral health; one of the CLC units; the medical 

VA OIG Office of Healthcare Inspections 2 
CAP Review of the Hunter Holmes McGuire VA Medical Center, Richmond, VA 

Recommendations 

Management of 

MDRO 

ICU; the telemetry unit; the surgical unit; two construction 

sites; and the radiology department, which includes nuclear 

medicine. The facility maintained a generally clean and safe 

environment. However, we identified the following conditions 

that needed improvement. 

Infection Control. OSHA requires that designated employees 

be fit tested annually if the facility uses respirators. We 

reviewed 25 employee training records and determined that 

only 13 (52 percent) of the employees had the required 

annual fit testing. 

Patient Privacy. The Health Insurance Portability and 

Accountability Act requires confidential PI to be secured. We 

found several areas in the facility with unsecured PI. Five 

office doors were open and contained unlocked computers or 

documents with confidential PI in plain view. 

1. We recommended that all designated employees 

complete annual N95 respirator fit testing and that the 

training be documented. 

2. We recommended strengthening processes to ensure 

that confidential PI is secured. 

The purpose of this review was to evaluate whether the 

facility had developed a safe and effective program to reduce 

the incidence of MDRO in its patient population in 

accordance with applicable requirements. 

We inspected the hospice, general medicine and oncology, 

and spinal cord injury and disorder units and one CLC unit, 

and we interviewed 10 employees. We identified no deficits 

in either the inspections or staff interviews. However, we 

identified the following area that needed improvement. 

Patient/Family Education. The JC requires that patients 

infected or colonized with MDRO and their families receive 

education on infection prevention strategies, such as hand 

washing and the proper use of PPE.1 We reviewed 

40 medical records and found that 18 (45 percent) of the 

records did not have documented evidence of MDRO 

education. 

1 Colonization is the presence of bacteria in the body without causing clinical infection. 

VA OIG Office of Healthcare Inspections 3 
CAP Review of the Hunter Holmes McGuire VA Medical Center, Richmond, VA 

Recommendation	 3. We recommended that infection prevention strategies 

education be provided to patients infected or colonized with 

MDRO and their families and be documented. 

Management of	 The purpose of this review was to follow up on a previous 

Test Results review that identified improvement opportunities related to 

documentation of notification of abnormal test results and 

follow-up actions taken.2 

We reviewed the facility’s policies and procedures, and we 

reviewed medical records. We identified the following area 

that needed improvement. 

Communication of Normal Results. VHA requires facilities to 

communicate normal results to patients no later than 

14 calendar days from the date that the results were 

available to the ordering provider.3 We reviewed the medical 

records of 20 patients who had normal results and found that 

only 12 (60 percent) of the 20 records contained documented 

evidence that the facility had communicated the results to the 

patients. 

Recommendation	 4. We recommended that normal test results be 

consistently communicated to patients within the specified 

timeframe. 

Physician C&P	 The purpose of this review was to determine whether the 

facility had consistent processes for physician C&P that 

complied with applicable requirements. 

We reviewed 15 physicians’ C&P files and profiles and found 

that licenses were current and that primary source 

verification had been obtained. However, we identified the 

following areas that needed improvement. 

Physician Privileges. VHA requires that when a facility 

grants a physician privileges to practice, the facility must 

determine whether the privileges should be restricted to 

specific care settings (such as the surgery suite, the ICU, or 

an outpatient clinic) and grant the privileges accordingly.4 Of 

the 15 C&P files we reviewed, 11 documented the granting 

of specialized privileges; however, specific care settings had 

not been appropriately identified. For example, a surgeon 

2 Healthcare Inspection Summary Review – Evaluation of Veterans Health Administration Procedures for
 

Communicating Abnormal Test Results, Report No. 01-01965-24, November 25, 2002.
 3 VHA Directive 2009-019, Ordering and Reporting Test Results, March 24, 2009.
 4 VHA Handbook 1100.19, Credentialing and Privileging, November 14, 2008.
 

VA OIG Office of Healthcare Inspections 4 
CAP Review of the Hunter Holmes McGuire VA Medical Center, Richmond, VA 

had been granted specialized surgical privileges, which 

required staffing and equipment support, in several settings, 

including the outpatient clinic. 

FPPE. VHA requires that an FPPE be initiated for all 

physicians who have been newly hired or have added new 

privileges and that results be reported to the MEC.5 The two 

newly hired physicians whose profiles we reviewed had 

FPPEs implemented; however, the results were not reported 

to the MEC. 

Recommendation	 5. We recommended that privileges appropriately indicate 

the setting where they may be practiced and that results of 

FPPE be reported to the MEC. 

Review Activities Without Recommendations 

COC	 The purpose of this review was to evaluate whether the 

facility managed advance care planning, advance directives, 

and discharges in accordance with applicable requirements. 

We reviewed 40 patients’ medical records and determined 

that the facility generally met requirements in these areas. 

We made no recommendations. 

Medication	 The purpose of this review was to determine whether the 

Management facility employed safe practices in the preparation, transport, 

and administration of hazardous medications, specifically 

chemotherapy, in accordance with applicable requirements. 

We observed the compounding and transportation of 

chemotherapy medications and the administration of those 

medications in the oncology clinic, and we interviewed 

employees. We determined that the facility safely prepared, 

transported, and administered the medications. We made no 

recommendations. 

QM	 The purpose of this review was to evaluate whether the 

facility had a comprehensive QM program in accordance with 

applicable requirements and whether senior managers 

actively supported the program’s activities. 

We interviewed senior managers and QM personnel, and we 

evaluated policies, meeting minutes, and other relevant 

documents. The QM program was generally compliant with 

5 VHA Handbook 1100.19. 

VA OIG Office of Healthcare Inspections 5 
CAP Review of the Hunter Holmes McGuire VA Medical Center, Richmond, VA 

requirements, and senior managers supported the program. 

We made no recommendations. 

Comments 

The VISN and Facility Directors agreed with the CAP review findings and 

recommendations and provided acceptable improvement plans. (See Appendixes D 

and E, pages 13–16, for the full text of the Directors’ comments.) We will follow up on 

the planned actions until they are completed. 

VA OIG Office of Healthcare Inspections 6 
CAP Review of the Hunter Holmes McGuire VA Medical Center, Richmond, VA 

Appendix A 

Facility Profile6 

Type of Organization Tertiary care medical center 

Complexity Level 1a 

VISN 6 

CBOCs Fredericksburg, VA 

Charlottesville, VA 

Emporia, VA 

Veteran Population in Catchment Area 209,073 

Type and Number of Total Operating Beds: 

 Hospital, including PRRTP 311 

 CLC/Nursing Home Care Unit 98 (includes 10 palliative care beds) 

 Other N/A 

Medical School Affiliation(s) Virginia Commonwealth University 

 Number of Residents 562 

FY 2010 (through 

June 2010) 

Prior FY (2009) 

Resources (in millions): 

 Total Medical Care Budget $342 $331 

 Medical Care Expenditures $259 $331 

Total Medical Care FTE 2,204 2,176 

Workload: 

 Number of Station Level Unique 

Patients 

41,459 43,290 

 Inpatient Days of Care: 

o Acute Care 49,702 61,738 

o CLC/Nursing Home Care Unit 20,297 27,807 

Hospital Discharges 5,895 7,074 

Total Average Daily Census (including all bed 

types) 

258 245 

Cumulative Occupancy Rate 63% 60% 

Outpatient Visits 353,593 444,721 

6 All data provided by facility management. 

VA OIG Office of Healthcare Inspections 7 
CAP Review of the Hunter Holmes McGuire VA Medical Center, Richmond, VA 

Appendix B 

Follow-Up on Previous Recommendations 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

Documentation of Intraoperative Clinical 

Information 

1. Allow only authorized staff with 

appropriate clinical privileges or scope of 

practice to document clinical information in 

patient medical records. 

Clerical staff no longer enter clinical 

data. All clinical information is entered 

by a clinical provider. 

Y N 

2. Ensure that the accuracy of 

intraoperative clinical information is 

monitored. 

All records from the 3rd quarter of 

FY 2007 have been reviewed for 

discrepancies between the nursing 

intraoperative report and the anesthesia 

record. At the time of the CAP survey in 

June 2007, approximately 50 percent of 

the records required corrections. For 

the first 2 quarters, the rate was 

8 percent. External Peer Review 

Package reviews revealed no 

discrepancies in subsequent quarters. 

Nursing and anesthesia no longer enter 

the same information, so there cannot 

be discrepancies. Anesthesia enters 

their data (antibiotic timing), and nursing 

enters theirs. 

Y N 

QM 

3. Ensure that the signed informed 

consents are obtained for outpatient 

surgical procedures. 

iMED consents are available in 

outpatient clinics. Monitoring for 

consents shows compliance with use of 

iMED. 

Y N 

VA OIG Office of Healthcare Inspections 8 
CAP Review of the Hunter Holmes McGuire VA Medical Center, Richmond, VA 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

4. Ensure full compliance with 

medication reconciliation requirements. 

Medication reconciliation has been 

added to all admission, discharge, and 

transfer templates as well as many 

outpatient clinic templates. Compliance 

is not consistent month to month and 

varies by service. 

Y N 

5. Ensure that peer reviews and RCAs are 

completed within the required periods. 

RCA completion is tracked and reported 

to leadership, the VISN, and the 

National Center for Patient Safety. 

Completion has been timely since the 

1st quarter of FY 2008. 

Peer reviews are tracked by 

spreadsheet and reported to the MEC 

and the VISN. The 120-day completion 

has been met for at least the last 

6 quarters. Initial peer review in 45 days 

is not 100 percent but has been greater 

than 90 percent. In the 2nd quarter of 

FY 2010, 110 reviews were done of 

which 106 were done within 45 days. 

Y N 

EOC 

6. Take appropriate action regarding 

employees who inaccurately documented 

defibrillator testing. 

Appropriate action was taken with 

employees involved in this incident. 

Nursing assures accurate 

documentation is a part of competency 

training. 

Y N 

VA OIG Office of Healthcare Inspections 9 
CAP Review of the Hunter Holmes McGuire VA Medical Center, Richmond, VA 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

7. Ensure that all defibrillators are tested as 

required by local policy. 

All nurses have been instructed on the 

defibrillator check procedures and 

documentation requirements. The 

code-cart documentation sheet was 

changed to require specific 

documentation of the defibrillator check 

and the test strip. All staff will be trained 

and competency assessed biannually. 

Nurse manager’s monitoring shows 

compliance with the new requirements. 

Y N 

VA OIG Office of Healthcare Inspections 10 
CAP Review of the Hunter Holmes McGuire VA Medical Center, Richmond, VA 

Appendix C 

VHA Satisfaction Surveys
 VHA has identified patient and employee satisfaction scores as significant indicators of 

facility performance. Patients are surveyed monthly. Table 1 below shows facility, 

VISN, and VHA overall inpatient and outpatient satisfaction scores and targets for 

quarters 1–3 of FY 2010. 

Table 1 

FY 2010 

(inpatient target = 64, outpatient target = 56) 

Inpatient 

Score 

Quarter 1 

Inpatient 

Score 

Quarter 2 

Inpatient 

Score 

Quarter 3 

Outpatient 

Score 

Quarter 1 

Outpatient 

Score 

Quarter 2 

Outpatient 

Score 

Quarter 3 

Facility 53.7 62.2 59.8 56.1 57.7 60.6 

VISN 59.9 65.7 61.5 50.7 50.9 52.2 

VHA 63.3 63.9 64.5 54.7 55.2 54.8 

Employees are surveyed annually. Figure 1 below shows the facility’s overall employee 

scores for 2008, 2009, and 2010. Since no target scores have been designated for 

employee satisfaction, VISN and national scores are included for comparison. 

0.0 

0.5 

1.0 

1.5 

2.0 

2.5 

3.0 

3.5 

4.0 

4.5 

5.0 

2008 2009 2010 

Facility 

VISN 

National 

VA ALL EMPLOYEE SURVEY 

OVERALL SATISFACTION Figure 1: 

LEVEL OF SATISFACTION 

VA OIG Office of Healthcare Inspections 11 
CAP Review of the Hunter Holmes McGuire VA Medical Center, Richmond, VA 

Hospital Outcome of Care Measures
 Hospital Outcome of Care Measures show what happened after patients with certain 

conditions7 received hospital care. The mortality (or death) rates focus on whether 

patients died within 30 days of their hospitalization. The rates of readmission focus on 

whether patients were hospitalized again within 30 days. Mortality rates and rates of 

readmission show whether a hospital is doing its best to prevent complications, teach 

patients at discharge, and ensure patients make a smooth transition to their home or 

another setting. The hospital mortality rates and rates of readmission are based on 

people who are 65 and older. These comparisons are “adjusted” to take into account 

their age and how sick patients were before they were admitted to the VA facility. 

Table 2 below shows the facility’s Hospital Outcome of Care Measures for 

FYs 2006–2009. 

Table 2 

Mortality Readmission 

Heart Attack CHF Pneumonia Heart Attack CHF Pneumonia 

Facility 14.91 10.07 16.07 20.97 23.27 16.68 

VHA 13.31 9.73 15.08 20.57 21.71 15.85 

7 CHF is a weakening of the heart’s pumping power. With heart failure, your body does not get enough oxygen and 

nutrients to meet its needs. A heart attack (also called acute myocardial infarction) happens when blood flow to a 

section of the heart muscle becomes blocked and the blood supply is slowed or stopped. If the blood flow is not 

restored in a timely manner, the heart muscle becomes damaged from lack of oxygen. Pneumonia is a serious lung 

infection that fills your lungs with mucus and causes difficulty breathing, fever, cough, and fatigue. 

VA OIG Office of Healthcare Inspections 12 
CAP Review of the Hunter Holmes McGuire VA Medical Center, Richmond, VA 

Appendix D 

VISN Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: January 7, 2011 

From: Director, Mid-Atlantic Health Care Network (10N6) 

Subject: CAP Review of the Hunter Holmes McGuire VA Medical 

Center, Richmond, VA 

To: Director, Washington, DC, Healthcare Inspections Division 

(54DC) 

Director, Management Review Service (VHA CO 10B5 Staff) 

1.	 Thank you for the opportunity to respond. 

2.	 The Hunter Holmes McGuire VA Medical Center, Richmond, VA 

concurs with the findings and has provided specific corrective actions 

for each recommendation. 

3.	 If further information is required, please contact Charles Sepich, 

FACHE, Director, Richmond VA Medical Center at (804) 675-5500. 

(original signed by:) 

DANIEL F. HOFFMANN, FACHE 

VA OIG Office of Healthcare Inspections 13 
CAP Review of the Hunter Holmes McGuire VA Medical Center, Richmond, VA 

Appendix E 

Facility Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: January 6, 2011 

From: Director, 

(652/00) 

Hunter Holmes McGuire VA Medical Center 

Subject: CAP Review of the Hunter Holmes McGuire VA 

Center, Richmond, VA 

Medical 

To: Director, Mid-Atlantic Health Care Network (10N6) 

This memo serves to acknowledge receipt and review of the draft CAP 

Report for the program review of the Hunter Holmes McGuire VA Medical 

Center, Richmond, Virginia. Thank you for the opportunity to comment on 

the recommendations for improvement contained in this report. If you 

have any questions, please do not hesitate to contact R. C. Polatty, MD, 

Chief of Quality Management at 804-675-5756. 

(original signed by:) 

CHARLES SEPICH, FACHE 

VA OIG Office of Healthcare Inspections 14 
 

CAP Review of the Hunter Holmes McGuire VA Medical Center, Richmond, VA 

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 all designated employees complete 

annual N95 respirator fit testing and that the training be documented. 

Concur. 

A master roster of required positions has been created and reviewed by Infection 

Control and Safety. This master roster will serve as a tracking mechanism for annual 

reviews. Safety is performing mass fit testing and documentation utilizing opportunities 

which include the following: Flu Clinic Blitz, New Employee Orientation, individual 

clinical units on a schedule, and Medical Grand Rounds. The status will be reported 

quarterly to the Environment of Care Committee and the Infection Control Committee 

with a goal of ≥ 95% compliance with ongoing monitoring after that. 

Target date: May 31, 2011. 

Recommendation 2. We recommended strengthening processes to ensure that 

confidential PI is secured. 

Concur. 

Medical team rooms and others with PI have new locks and codes will be distributed to 

staff for use to secure information. The ACOS of Education has established a 

spreadsheet that will be used by service line resident coordinators to ensure the 

distribution of resident workroom lock codes. The spreadsheet will reflect the primary 

contact and other information that will be useful to the hospital’s residents and 

attendings for accountability. Environment of Care Rounds, tracer activity, and the 

Privacy Officer will survey for information or computers that are unsecured and inform 

leadership for immediate correction. 

The weekly newsletter and electronic message boards will also be used to re-educate 

staff on the importance of proper privacy practices. 

Target date: March 31, 2011 

Recommendation 3. We recommended that infection prevention strategies education 

be provided to patients infected or colonized with MDRO and their families and be 

documented. 

Concur. 

VA OIG Office of Healthcare Inspections 15 
CAP Review of the Hunter Holmes McGuire VA Medical Center, Richmond, VA 

Epidemiology has developed educational materials and trained nursing staff on their 

use to educate patients and families on MDRO. There is an order entered on admission 

for education and a template has been made for nursing documentation of education in 

CPRS. Documentation has begun and is ongoing. Documentation of education is 

being will be monitored and reported monthly to the Quality Executive Board. 

Target Date: March 31, 2011 

Recommendation 4. We recommended that normal test results be consistently 

communicated to patients within the specified timeframe. 

Concur. 

All clinical services will develop a process to notify patients of test results within 14 days 

of availability unless the criticality of the result demands more immediate action. Per 

our bylaws, this may be done by face to face visit, phone encounter, or letter. The letter 

template used successfully by Primary Care has been made available to all services to 

adapt for their results. Services will review records monthly to ensure compliance and 

report to the Medical Executive Board. 

Target Date: March 31, 2011 

Recommendation 5. We recommended that privileges appropriately indicate the 

setting where they may be practiced and that results of FPPE be reported to the MEC. 

Concur. 

A tracking process for reporting FPPE's has been developed. FPPE's were reported to 

the Medical Professional Standards Board since November 2010 and will continue to be 

reported there and documented in minutes. Site specific privileging forms are being 

developed for each service and will be used with new and recurring privileges once 

forms are developed and approved by the Medical Executive Board. 

Target Date: April 30, 2011 

VA OIG Office of Healthcare Inspections 16 
CAP Review of the Hunter Holmes McGuire VA Medical Center, Richmond, VA 

Appendix F 

OIG Contact and Staff Acknowledgments 

Contact	 Donna Giroux, Associate Director 

Washington, DC, Office of Healthcare Inspections 

Contributors	 Bruce Barnes 

Jennifer Christensen 

Kathy Gudgell 

Sandra Khan 

Frank Miller 

Kimberly Pugh 

Randall Snow 

Sonia Whig 

Natalie Sadow-Colón, Program Support Assistant 

Michael Kurisky, Washington, DC, Office of Investigations 

Darren Petri, Washington, DC, Office of Investigations 

VA OIG Office of Healthcare Inspections 17 
CAP Review of the Hunter Holmes McGuire VA Medical Center, Richmond, VA 

Appendix G 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VA Mid-Atlantic Health Care Network (10N6) 

Director, Hunter Holmes McGuire VA Medical Center (652/00) 

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: Mark R. Warner, Jim Webb 

U.S. House of Representatives: Robert C. “Bobby” Scott 

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

VA OIG Office of Healthcare Inspections 18