Department of Veterans Affairs 

Office of Inspector General 

Office of Healthcare Inspections
 

Report No. 10-02982-73 

Combined Assessment Program
 

Review of the
 

Alexandria VA Medical Center
 

Pineville, Louisiana
 

January 24, 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 Alexandria VA Medical Center, Pineville, LA 

Glossary 

C&P credentialing and privileging 

CAP Combined Assessment Program 

CBOC community based outpatient clinic 

CCC Critical Care Committee 

CHF congestive heart failure 

CLC community living center 

COC coordination of care 

ED emergency department 

EMR electronic medical record 

EMT emergency medical technician 

EOC environment of care 

facility Alexandria VA Medical Center 

FPPE Focused Professional Practice Evaluation 

FTE full-time employee equivalents 

FY fiscal year 

IC infection control 

JC Joint Commission 

MDRO multidrug-resistant organisms 

MH mental health 

MHEOCC Mental Health Environment of Care Checklist 

MSIT Multidisciplinary Safety Inspection Team 

OIG Office of Inspector General 

OPPE Ongoing Professional Practice Evaluation 

PI performance improvement 

PRRTP Psychosocial Residential Rehabilitation Treatment 

Program 

PSB Professional Standards Board 

QM quality management 

RCA root cause analysis 

RRT Rapid Response Team 

SR systems redesign 

VHA Veterans Health Administration 

VISN Veterans Integrated Service Network 

VA OIG Office of Healthcare Inspections 
CAP Review of the Alexandria VA Medical Center, Pineville, LA 

Table of Contents 

Page
 

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

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

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

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

Reported Accomplishment........................................................................................ 2
 

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

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

QM..................................................................................................................... 3
 

Physician C&P................................................................................................... 3
 

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

Management of MDRO...................................................................................... 4
 

EOC................................................................................................................... 5
 

Review Activities Without Recommendations ......................................................... 6
 

COC .................................................................................................................. 6
 

Medication Management ................................................................................... 6
 

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 ......................................................... 18
 

G. Report Distribution ............................................................................................ 19
 

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

Review of the Alexandria VA Medical Center, Pineville, LA 

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 

activities: 

 Coordination of Care 

 Medication Management 

The facility’s reported accomplishment 

was its cancer care collaborative, which 

reduced the number of days between 

initial suspicion of cancer to actual 

diagnosis. 

Recommendations: We made 

recommendations in the following five 

activities: 

Quality Management: The Critical 

Care Committee should review all 

resuscitation events occurring in the 

facility, and facility policy should be 

revised to include the roles and 

responsibilities of the emergency 

medical technicians on the Rapid 

Response Team. 

Physician Credentialing and Privileging: 

Focused Professional Practice 

Evaluations should be initiated for all 

physicians who have been newly hired, 

and Professional Standards Board 

minutes need to reflect discussion of 

Focused Professional Practice 

Evaluations. Ongoing Professional 

Practice Evaluations should reflect the 

aggregate performance data used to 

validate competency. 

Management of Test Results: Normal 

test results must be consistently 

communicated to patients within the 

specified timeframe. 

Management of Multidrug-Resistant 

Organisms: Infection control strategies 

education should be provided to 

patients infected or colonized with 

multidrug-resistant organisms and their 

families and should be documented. 

Environment of Care: Staff designated 

as high risk for exposure to airborne 

pathogens should receive annual 

respirator fit testing. 

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 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 Alexandria VA Medical Center, Pineville, LA 

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 2009 and 

FY 2010 through September 11, 2010, 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 facility (Combined 

Assessment Program Review of the Alexandria VA Medical 

Center, Pineville, Louisiana, Report No. 08-00054-84, 

VA OIG Office of Healthcare Inspections 1 
CAP Review of the Alexandria VA Medical Center, Pineville, LA 

February 27, 2008). During our follow-up review, we found 

sufficient evidence that program managers and staff had 

implemented appropriate actions to address the identified 

deficiencies in these areas. We consider these issues 

closed. (See Appendix B for further details.) 

During this review, we also presented crime awareness 

briefings for 155 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 Accomplishment 

In 2009, the facility initiated a project to reduce the number 

of days from initial suspicion of lung cancer to diagnosis and 

treatment by improving timeliness of providers ordering and 

completing follow-up diagnostic testing on abnormal imaging 

results. The project was developed in response to VHA SR 

efforts, and in February 2010, the facility was 1 of 20 teams 

selected to participate in the national Cancer Care 

Collaborative to work on initiatives to improve the timeliness 

and reliability of cancer care across VHA. Through improved 

communication, effective utilization of data collection tools, 

team accountability, and feedback, the facility was able to 

reduce the number of days between initial suspicion of 

cancer to actual diagnosis. Timely diagnosis allows for more 

timely initiation of therapy. 

Table A. Compliance with Performance Measure (in percent) 

Cancer Care
 

Collaborative
 

Calendar Year 

2009 

Calendar Year 

2010 through 

March 

Abnormal chest x-ray(s) 

follow-up test ordered 

within 3 days 

61 92 

Follow-up diagnostic 

testing completed within 

7 days 

58 77 

VA OIG Office of Healthcare Inspections 2 
CAP Review of the Alexandria VA Medical Center, Pineville, LA 

Results 

Review Activities With 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. We identified the following area that needed 

improvement. 

Review of Resuscitation and Its Outcomes. Facility policy 

defined the roles, responsibilities, and documentation 

requirements for staff responding to resuscitation events, 

including the RRT. In addition, facility policy required CCC 

review of all resuscitation events. However, we found that 

RRT responses that occurred outside the inpatient building 

were not included as part of the CCC review. We also found 

that facility policy did not define the roles and responsibilities 

for EMTs who responded as the RRT outside of the inpatient 

building. 

Recommendations	 1. We recommended that the CCC review all resuscitation 

events occurring in the facility and that facility policy be 

revised to include the roles and responsibilities of the EMTs 

on the RRT. 

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 10 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. 

FPPE. VHA requires that an FPPE be initiated for all 

physicians who have been newly hired or have added new 

privileges.1 VHA also requires that PSB minutes reflect 

discussion of completed FPPEs. One of the three newly 

hired physicians whose profiles we reviewed did not have an 

FPPE implemented. In addition, PSB minutes did not reflect 

discussion of one of the two completed FPPEs. 

1 VHA Handbook 1100.19, Credentialing and Privileging, November 14, 2008. 

VA OIG Office of Healthcare Inspections 3 
CAP Review of the Alexandria VA Medical Center, Pineville, LA 

Recommendations 

Management of 

Test Results 

Recommendation 

Management of 

MDRO 

OPPE. VHA requires that data consistent with 

service-specific competency criteria be collected, maintained 

in each physician’s profile, and reviewed on an ongoing 

periodic basis.2 We found evidence of OPPE performance 

data in the profiles. However, the OPPEs only reflected data 

related to predefined triggers, which would indicate a need 

for closer review. The OPPEs did not reflect the aggregated 

performance data to support competency. 

2. We recommended that FPPEs be initiated for all 

physicians who have been newly hired and that PSB minutes 

reflect discussion of FPPEs. 

3. We recommended that OPPEs reflect the aggregated 

performance data used to validate competency. 

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

review that identified improvement opportunities related to 

documentation of notification of abnormal test results and 

follow-up actions taken.3 

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.4 We reviewed the medical 

records of 20 patients who had normal results and found that 

only 10 (50 percent) of the 20 records contained 

documented evidence that the facility had communicated the 

results to the patients. 

4. We recommended that normal test results be 

consistently communicated to patients within the specified 

timeframe. 

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. 

2 VHA Handbook 1100.19.
 3 Healthcare Inspection Summary Review – Evaluation of Veterans Health Administration Procedures for
 

Communicating Abnormal Test Results, Report No. 01-01965-24, November 25, 2002.
 4 VHA Directive 2009-019, Ordering and Reporting Test Results, March 24, 2009.
 

VA OIG Office of Healthcare Inspections 4 
CAP Review of the Alexandria VA Medical Center, Pineville, LA 

We reviewed the facility’s IC risk assessment, employee 

training records, and medical records. We inspected the 

CLC (45-C2) and the acute inpatient medicine/surgery (7BN) 

units, and we interviewed six employees. We did not identify 

any 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 colonized5 with MDRO receive education on IC 

strategies, such as hand washing and the proper use of 

personal protective equipment. We reviewed 16 medical 

records and found that 3 (19 percent) of the records did not 

have documented evidence of MDRO education. 

Recommendation	 5. We recommended that IC strategies education be 

provided to patients infected or colonized with MDRO and 

their families and be documented. 

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 locked MH (9A&B), acute inpatient 

medicine/surgery (7A), intensive care (7B), Alzheimer’s 

(45-A), long-term care and hospice (45-B), and 

post-anesthesia care units. We also inspected the ED; the 

dental, eye, and podiatry clinics; and four primary care 

outpatient (B, C, E, and F) clinics. The facility maintained a 

generally clean and safe environment. However, we 

identified the following area that needed improvement. 

Respirator Fit Testing. The Occupational Safety and Health 

Administration requires that staff at risk for exposure to 

airborne pathogens, such as swine flu or tuberculosis, have 

annual respirator fit testing. We found that 6 (40 percent) of 

15 employees who were designated as high risk did not have 

the required annual respirator fit testing. Five of the six 

employees were assigned to the ED. 

Recommendation	 6. We recommended that staff designated as high risk for 

exposure to airborne pathogens receive annual respirator fit 

testing. 

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

VA OIG Office of Healthcare Inspections 5 
CAP Review of the Alexandria VA Medical Center, Pineville, LA 

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 16 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. 

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 13–17, for the full text of the Directors’ comments.) We will follow up on 

planned actions until they are completed. 

VA OIG Office of Healthcare Inspections 6 
CAP Review of the Alexandria VA Medical Center, Pineville, LA 

Appendix A 

Facility Profile6 

Type of Organization Primary and secondary care medical center 

Complexity Level 3 

VISN 16 

CBOCs Lafayette, LA 

Jennings, LA 

Natchitoches, LA (opened 10/4/10) 

Veteran Population in Catchment Area 89,198 

Type and Number of Total Operating Beds: 

 Hospital, including PRRTP 114 

 CLC/Nursing Home Care Unit 112 

 Other 0 

Medical School Affiliation Tulane University School of Medicine, 

Sections of Preventative Medicine and 

Ophthalmology 

 Number of Residents 13 

Current FY (through 

August 2010) 

Prior FY (2009) 

Resources (in millions): 

 Total Medical Care Budget $186.1 $185.6 

 Medical Care Expenditures $168 $185.4 

Total Medical Care FTE 1,184 1,182 

Workload: 

 Number of Station Level Unique 

Patients 

27,726 28,191 

 Inpatient Days of Care: 

o Acute Care 8,367 10,130 

o CLC/Nursing Home Care Unit 29,504 36,159 

Hospital Discharges 1,321 1,488 

Total Average Daily Census (including all bed 

types) 

148.6 157.1 

Cumulative Occupancy Rate 69.6% 69.5% 

Outpatient Visits 191,339 222,166 

6 All data provided by facility management. 

VA OIG Office of Healthcare Inspections 7 
CAP Review of the Alexandria VA Medical Center, Pineville, LA 

Appendix B 

Follow-Up on Previous Recommendations 

Recommendations Current Status of Corrective Actions Taken In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

QM 

1. Complete the RCA 

process in accordance with 

VHA policy. 

Facility has a policy that contains an RCA 

checklist. The patient safety manager 

developed an RCA action item tracking log and 

record system. 

Y N 

2. Timely review all deaths to 

identify issues that may 

require follow-up. 

Facility established a computerized menu option 

that tracks death reviews to completion, 

automatically generating and printing a daily 

report in PI. Daily, an administrative person 

assigns newly identified death reviews to PI 

staff. 

Y N 

EOC 

3. Track and report all 

findings, actions, and 

outcomes from safety rounds 

on the locked MH unit, as 

required by the Deputy Under 

Secretary for Health for 

Operations and Management. 

The MHEOCC is presented quarterly as a 

separate agenda item at EOC Committee 

meetings. Once environmental concerns are 

identified, the level of risk is rated, a corrective 

action plan is developed, and progress is 

monitored until closed. 

Y N 

4. Complete an interim 

corrective action plan to 

address environmental safety 

concerns on the locked MH 

unit that pose a risk but cannot 

be immediately corrected. 

The MHEOCC is presented quarterly as a 

separate agenda item at EOC Committee 

meetings. Once environmental concerns are 

identified, the level of risk is rated, a corrective 

action plan is developed, and progress is 

monitored until closed. 

Y N 

VA OIG Office of Healthcare Inspections 8 
CAP Review of the Alexandria VA Medical Center, Pineville, LA 

Recommendations Current Status of Corrective Actions Taken In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

5. Ensure all staff assigned to 

the locked MH unit and all 

members of the MSIT receive 

training on identifying and 

correcting environmental 

hazards. 

One-hundred percent in compliance. All locked 

MH unit staff and all members of the MSIT 

completed training on identifying and correcting 

environmental hazards. 

Y N 

EMR Business Rules 

6. Continue compliance with 

VHA Handbook 1907.01 and 

the October 2004 Office of 

Information guidance related to 

EMRs. 

This recommendation was closed during the 

December 2007 onsite visit. The facility 

continues to comply. 

Y N 

Patient Satisfaction 

7. Develop a comprehensive 

Survey of Healthcare 

Experiences of Patients 

program that includes specific 

service-level action planning 

and follow-up. 

In FY 2009, three SR teams were chartered to 

improve inpatient and outpatient satisfaction. 

Through effective communication, health care 

information, and education, there was a 

5 percent improvement in inpatient MH, 

Lafayette CBOC, and facility outpatient 

satisfaction scores. Based on FY 2009 scores, 

a facility-wide customer service redesign team 

was chartered. Its aims were to improve 

inpatient and outpatient overall quality in 

FY 2010 and to decrease the number of patient 

complaints in inpatient, outpatient, and CLC 

areas. 

Y N 

VA OIG Office of Healthcare Inspections 9 
CAP Review of the Alexandria VA Medical Center, Pineville, LA 

Recommendations Current Status of Corrective Actions Taken In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

8. Ensure Customer Service 

Council minutes include all 

appropriate elements and 

show continuity of process 

from month to month. 

Monthly Customer Service Council minutes 

include all appropriate elements and show 

continuity of process from month to month. 

Identification and correction of customer 

complaint(s) and customer service issues are 

reviewed at Director’s Staff Leadership Council. 

Y N 

VA OIG Office of Healthcare Inspections 10 
CAP Review of the Alexandria VA Medical Center, Pineville, LA 

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 74.2 60.9 68.2 58.1 61.1 56.0 

VISN 66.1 64.6 63.1 53.1 54.3 54.6 

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 Alexandria VA Medical Center, Pineville, LA 

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 11.77 9.68 16.37 20.03 21.09 15.01 

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 sedition of 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 Alexandria VA Medical Center, Pineville, LA 

Appendix D 

VISN Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: December 23, 2010 

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

Subject: CAP Review of the Alexandria VA Medical Center, 

Pineville, LA 

To: Director, Atlanta Office of Healthcare Inspections (54AT) 

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

I have reviewed the recommendations and concur with the response and 

action plans. If you have any questions, please contact Mary Jones, HSS 

at 601-206-6974. 

(original signed by:) 

George H. Gray, Jr. 

Network Director 

VA OIG Office of Healthcare Inspections 13 
CAP Review of the Alexandria VA Medical Center, Pineville, LA 

Appendix E 

Facility Director Comments 

Department of 

Veterans Affairs Memorandum 

Date:	 December 21, 2010 

From:	 Director, Alexandria VA Medical Center (502/00) 

Subject:	 CAP Review of the Alexandria VA Medical Center, 

Pineville, LA 

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

1. Our comments and actions plans have been entered directly in this 

report as requested. 

2. Should you need additional information, please contact 

Portia McDaniel, RN, BSN, Chief, Performance Improvement, at 

(318) 4566-2370. 

(original signed by:) 

Gracie Specks, MS, MBA 

VA OIG Office of Healthcare Inspections 14 
CAP Review of the Alexandria VA Medical Center, Pineville, LA 

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 the CCC review all resuscitation events 

occurring in the facility and that facility policy be revised to include the roles and 

responsibilities of the EMTs on the RRT. 

Concur 

Target date for completion: January 13, 2011 

The current function of the CCC includes a review of all resuscitation events that occur 

at the facility. Medical Center policy, MCM-11-29, Critical Care Committee, documents 

the function. The facility is in the process of changing the policies and procedures 

related to emergency response. EMT’s will no longer respond to RRT in Bldg 7. The 

Medical Center policy, MCM 138S-33, Medical Emergency Responses: Outside 

Building 7, has been developed to delineate the roles and responsibilities of the EMT’s. 

The policy is currently under review by the CCC and EOC. It will be sent for final 

concurrence no later than December 23, 2010. The existing policy, MCM 111-36, Rapid 

Response Team, will remain in effect for Bldg. 7 only. 

Recommendation 2. We recommended that FPPEs be initiated for all physicians who 

have been newly hired and that PSB minutes reflect discussion of FPPEs. 

Concur 

Target date for completion: Completed November 16, 2010 

The medical center has initiated FPPE’s for all physicians who have been hired and will 

continue this process on each new hire. The PSB minutes reflect discussion of the 

FPPE for all new hires. The content of the PSB minutes has been updated to 

strengthen the evidence of the discussion. November 2010 minutes document the 

FPPE discussion for the most recent hire that was boarded on November 16, 2010. 

Recommendation 3. We recommended that OPPEs reflect the aggregated 

performance data used to validate competency. 

Concur 

Target date for completion: January 13, 2011 

VA OIG Office of Healthcare Inspections 15 
CAP Review of the Alexandria VA Medical Center, Pineville, LA 

The medical center continues to utilize performance data to validate the competency for 

all physicians. The OPPE data has been updated to reflect aggregated outcomes for 

each physician. 

Recommendation 4. We recommended that normal test results be consistently 

communicated to patients within the specified timeframe. 

Concur 

Target date for completion: Completed December 9, 2010 

The medical center has distributed instructions to providers regarding the 

communication of normal test results to patients within the specified timeframe. A 

template field has been added to the provider ambulatory care progress note. A 

random sample of patients who have had an outpatient encounter has been reviewed. 

The medical center reviewed 6 records for patients receiving care through 

December 2010. The documentation revealed that all patient records contained 

documentation that normal test results were communicated to the patient within 

14 days. The data from this review is available upon request. 

Recommendation 5. We recommended that infection control strategies education be 

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

documented. 

Concur 

Target date for completion: Completed November 26, 2010 

The Infection Control program has developed a patient education package for each 

patient admitted to the facility. The package contains education material to include 

MDRO prevention strategies. Nursing staff provides the package to the patient and 

family members during the admission process. A review of the content occurs 

throughout the patient’s encounter at the facility. For the Community Living Center, 

residents lacking capacity to manage their own affairs, education materials are being 

sent to surrogates/next of kin via mail to ensure infection prevention education has been 

provided. Documentation of the education provided is written in the medical record. A 

sample record review of patients who were infected or colonized with MDRO was 

completed. The results of this review revealed that all patient records contained 

documentation of infection control strategies. 

Recommendation 6. We recommended that staff designated as high risk for exposure 

to airborne pathogens receive annual respirator fit testing. 

Concur 

Target date for completion: January 13, 2011 

VA OIG Office of Healthcare Inspections 16 
CAP Review of the Alexandria VA Medical Center, Pineville, LA 

The medical center has identified staff that is designated as high risk for exposure to 

airborne pathogens. The Safety Office has identified a labor pool of six staff that is 

trained in fit testing procedures. The medical center determines whether an employee 

is cleared for fit testing during the pre-employment exam. Once the staff reports to duty, 

the fit testing is completed during the service level orientation. This process has been 

implemented in Nursing Service and will be rolled out to the remaining high risk for 

exposure work units. The labor pool is currently working to ensure that all high risk for 

exposure to airborne pathogens staff is current with their annual requirements. The 

staff that is due to complete annual respirator fit testing will complete the requirement no 

later than January 13, 2011. 

VA OIG Office of Healthcare Inspections 17 
CAP Review of the Alexandria VA Medical Center, Pineville, LA 

Appendix E 

OIG Contact and Staff Acknowledgments 

Contact Audrey Collins-Mack, Team Leader 

Atlanta Office of Healthcare Inspections 

Contributors Tishanna McCutchen 

Judy Montano 

Karen Sutton 

Toni Woodard 

Susan Zarter 

Thomas Bennett, Office of Investigations 

Ryan Gholson, Office of Investigations 

VA OIG Office of Healthcare Inspections 18 
CAP Review of the Alexandria VA Medical Center, Pineville, LA 

Appendix F 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

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

Director, Alexandria VA Medical Center (502/00) 

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: Mary L. Landrieu, David Vitter 

U.S. House of Representatives: Rodney Alexander; Charles W. Boustany, Jr.; 

John Fleming 

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

VA OIG Office of Healthcare Inspections 19