Department of Veterans Affairs 

Office of Inspector General 

Office of Healthcare Inspections
 

Report No. 11-01298-268 

Combined Assessment Program
 

Review of the
 

Wilkes-Barre VA Medical Center
 

Wilkes-Barre, Pennsylvania
 

September 1, 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 Wilkes-Barre VA Medical Center, Wilkes-Barre, PA 

Glossary 

C&P credentialing and privileging 

CAP Combined Assessment Program 

EN enteral nutrition 

EOC environment of care 

facility Wilkes-Barre VA Medical Center 

FY fiscal year 

OIG Office of Inspector General 

PR peer review 

QM quality management 

RN registered nurse 

VHA Veterans Health Administration 

VISN Veterans Integrated Service Network 

VA OIG Office of Healthcare Inspections 
CAP Review of the Wilkes-Barre VA Medical Center, Wilkes-Barre, PA 

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
 

RN Competencies ............................................................................................. 4
 

QM..................................................................................................................... 4
 

Coordination of Care ......................................................................................... 5
 

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

EN Safety .......................................................................................................... 5
 

Management of Workplace Violence................................................................. 6
 

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

Physician C&P................................................................................................... 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................ 10
 

D. VISN Director Comments .................................................................................. 12
 

E. Facility Director Comments ............................................................................... 13
 

F. OIG Contact and Staff Acknowledgments ......................................................... 19
 

G. Report Distribution ............................................................................................ 20
 

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

Review of the Wilkes-Barre VA Medical Center,
 

Wilkes-Barre, PA
 

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 

May 9, 2011. 

Review Results: The review covered 

eight activities. We made no 

recommendations in the following 

activities: 

	 Enteral Nutrition Safety 

	 Management of Workplace Violence 

	 Medication Management 

	 Physician Credentialing and 

Privileging 

The facility’s reported accomplishments 

were the institution of a daily suicide 

prevention meeting and the 

development of an automated policy 

tracking system to ensure timely 

completion of new facility policies. 

Recommendations: We made 

recommendations in the following four 

activities: 

Environment of Care: Correct identified 

infection prevention and cleanliness 

deficiencies. Ensure that all open 

medications are labeled with expiration 

dates and that all required team 

members consistently attend 

environment of care rounds. 

Registered Nurse Competencies: 

Ensure that competency documents 

contain all required signatures and 

dates. 

Quality Management: Ensure that 

moderate sedation documentation 

includes all required elements and that 

supervisors monitor compliance. 

Require the Director to approve all peer 

review extensions in writing. 

Coordination of Care: Ensure that 

advance directive screening is accurate 

and that patients’ hard copy advance 

directives are scanned into the 

electronic medical record. 

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. 

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

Assistant Inspector General for
 

Healthcare Inspections
 

VA OIG Office of Healthcare Inspections i 
CAP Review of the Wilkes-Barre VA Medical Center, Wilkes-Barre, PA 

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 eight activities: 

	 Coordination of Care 

	 EN Safety 

	 EOC 

	 Management of Work Place Violence 

	 Medication Management 

	 Physician C&P 

	 QM 

	 RN Competencies 

The review covered facility operations for FY 2010 and 

FY 2011 through May 9, 2011, 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 Wilkes-Barre VA Medical Center, 

VA OIG Office of Healthcare Inspections 1 
CAP Review of the Wilkes-Barre VA Medical Center, Wilkes-Barre, PA 

Wilkes-Barre, Pennsylvania, Report No. 07-03445-97, 

March 17, 2008). (See Appendix B for further details) The 

facility had a repeat finding in the area of EOC rounds. 

During this review, we also presented crime awareness 

briefings for 186 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
 Suicide Prevention 

Daily Meeting 

Automated Medical 

Center Policy 

Tracking 

Individuals with key responsibilities for the prevention and 

management of veterans at high risk for suicide meet daily 

with the Suicide Prevention Coordinator. They discuss all 

contacts with veterans at high risk for suicide during the past 

24 hours and ensure the safety of these veterans by 

instituting all possible interventions. In addition, the meeting 

serves as a mechanism to identify process issues and 

barriers that impede efficient and effective services. The 

information discussed is communicated to the facility’s 

Director daily. 

The Automated Medical Center Policy Concurrence Process 

was developed using SharePoint. Once a policy is 

developed, it is uploaded to the site and automatically routed 

for concurrence. All responses and delinquencies are 

tracked. Once the policy is finalized, an automated 

message is sent to all facility employees notifying them of the 

new policy. In addition, the system fosters excellent 

coordination and communication between services and 

leadership, allows for efficient policy searches, and improves 

team productivity. This green initiative allows information to 

be compiled as one document and reduces the need for 

multiple e-mails and hard copies. 

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. 

VA OIG Office of Healthcare Inspections 2 
CAP Review of the Wilkes-Barre VA Medical Center, Wilkes-Barre, PA 

We inspected the locked mental health, intensive 

care/telemetry, community living center, medical/surgical, 

post-anesthesia care, and special procedures units. We also 

inspected the emergency department and the dental and eye 

clinics. The facility maintained a generally clean and safe 

environment. However, we identified the following conditions 

that needed improvement. 

Infection Prevention and Cleanliness. The Joint Commission 

requires that facilities reduce the risk of infections associated 

with the storage of medical equipment, devices, and 

supplies. Local policy requires that wheelchairs have a 

colored tag with the cleaning date attached to the back of 

each chair. We found equipment and supplies that were not 

clearly marked as clean stored in clean utility rooms, suction 

devices that were unpackaged at unoccupied bedsides, and 

low-lying shelving that did not allow for proper cleaning of the 

floor under the shelves. Additionally, we found many 

wheelchairs stored in the emergency department that were 

ready for patient use but were not properly tagged. 

Medication Safety and Security. The Joint Commission 

requires that opened medications be labeled with expiration 

dates. On two units, we found open medication vials that 

were not labeled with expiration dates. 

EOC Rounds. VHA policy requires the Director or the 

Associate Director to lead weekly EOC rounds.1 Participants 

should include managers in nursing, building management, 

engineering, safety, patient safety, infection control, 

information security, and others as required. We found that 

required team members’ attendance at these rounds has 

been inconsistent. This was a repeat finding from the 

previous CAP review. 

Recommendations	 1. We recommended that the identified infection prevention 

and cleanliness deficiencies be corrected. 

2. We recommended that processes be strengthened to 

ensure that all open medications are labeled with expiration 

dates. 

3. We recommended that all required EOC team members 

consistently attend EOC rounds. 

1 Deputy Under Secretary for Health for Operations and Management, “Environmental Rounds,” memorandum, 

March 5, 2007. 

VA OIG Office of Healthcare Inspections 3 
CAP Review of the Wilkes-Barre VA Medical Center, Wilkes-Barre, PA 

RN Competencies	 The purpose of this review was to determine whether the 

facility had an adequate RN competency assessment and 

validation process. 

We reviewed facility policy, interviewed nurse leaders, and 

reviewed initial and ongoing competency assessment and 

validation documents for 12 RNs. We identified the following 

area that needed improvement. 

Competency Validation Documentation. Local policy 

requires that both the employee and supervisor sign the 

competency document. In addition, the supervisor must sign 

and date each item in the document. Nine out of the 12 RN 

competency folders reviewed had missing signatures and/or 

incomplete or missing dates. 

Recommendation	 4. We recommended that processes be strengthened to 

ensure that competency documents contain all required 

signatures and dates. 

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 areas that needed 

improvement. 

Moderate Sedation. VHA policy requires facilities to 

document patient assessment prior to use of moderate 

sedation.2 We reviewed the medical records of 10 patients 

who had selected procedures where moderate sedation was 

used and found that 6 of the records had missing elements. 

Missing elements included airway assessment, review of 

organ systems, and assessment of risk. 

PR. VHA policy requires written approval by the facility’s 

Director for an extension on any PR that will exceed the 

120-day deadline for completion.3 For FY 2010 and the 

1st quarter of FY 2011, we found four PRs that were not 

completed within 120 days, and none had the Director’s 

written approval for an extension. 

2 VHA Directive 2006-023, Moderate Sedation by Non-Anesthesia Providers, May 1, 2006. 3 VHA Directive 2010-025, Peer Review for Quality Management, June 3, 2010. 

VA OIG Office of Healthcare Inspections 4 
CAP Review of the Wilkes-Barre VA Medical Center, Wilkes-Barre, PA 

Recommendations	 5. We recommended that moderate sedation 

documentation include all required elements and that 

supervisors monitor compliance. 

6. We recommended that the Director approve all PR 

extensions in writing. 

Coordination of	 The purpose of this review was to evaluate whether the 

Care facility managed advance care planning and advance 

directives in accordance with applicable requirements. 

We reviewed patients’ medical records for evidence of 

advance directive notification, advance directive screening, 

and documentation of advance care planning discussions. 

We also reviewed the facility’s policy to determine whether it 

was consistent with VHA policy. We identified the following 

area that needed improvement. 

Advance Directive Screening Accuracy. VHA requires that 

staff screen patients at each admission to a VHA facility to 

determine whether they have an advance directive and 

document the screening in the medical record. If a patient 

reports having an advance directive, staff should attempt to 

obtain the document and scan it into the electronic medical 

record. We found that screening was inaccurate in 5 of the 

20 patient medical records reviewed. One screening 

documented that there was no advance directive; however, 

we located an advance directive in the electronic medical 

record. Four screenings documented the presence of an 

advance directive; however, we could not locate one in the 

medical record, and there was no note requesting that the 

patient provide a copy to the facility. 

Recommendation	 7. We recommended that processes be strengthened to 

ensure that advance directive screening is accurate and that 

patients’ hard copy advance directives are scanned into the 

electronic medical record. 

Review Activities Without Recommendations
 

EN Safety	 The purpose of this review was to evaluate whether the 

facility established safe and effective EN procedures and 

practices in accordance with applicable requirements. 

We reviewed policies and documents related to EN and 

patients’ medical records. We also inspected areas where 

EN products were stored while conducting the EOC review, 

and we interviewed key employees. We determined that the 

VA OIG Office of Healthcare Inspections 5 
CAP Review of the Wilkes-Barre VA Medical Center, Wilkes-Barre, PA 

facility generally met EN safety requirements. We made no 

recommendations. 

Management of	 The purpose of this review was to determine whether VHA 

Workplace facilities issued and complied with comprehensive policy 

regarding violent incidents and provided required training. Violence 

We reviewed the facility’s policy and training plan. Although 

the facility did not have any incidents of assault in the past 

2 years, it did have a comprehensive workplace violence 

policy. The training plan addressed the required prevention 

and management of disruptive behavior training. 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. 

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 C&P files and profiles and meeting minutes 

during which discussions about the physicians took place. 

We determined that the facility had implemented a consistent 

C&P process that met current requirements. 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 12–18, for the full text of the Directors’ comments.) We consider 

Recommendations 2 and 6 closed. We will follow up on the planned actions for the 

open recommendations until they are completed. 

VA OIG Office of Healthcare Inspections 6 
CAP Review of the Wilkes-Barre VA Medical Center, Wilkes-Barre, PA) 

Appendix A 

Facility Profile4 

Type of Organization Teaching hospital that provides primary and 

tertiary services 

Complexity Level 2 

VISN 4 

Community Based Outpatient Clinics Allentown, PA 

Sayre, PA 

Williamsport, PA 

Tobyhanna, PA 

Berwick, PA 

Bangor, PA 

Veteran Population in Catchment Area 173,296 (Projected for FY 2011) 

Type and Number of Total Operating Beds: 

 Hospital, including Psychosocial 

Residential Rehabilitation Treatment 

Program 

68 

 Community Living Center/Nursing 

Home Care Unit 

105 

 Other N/A 

Medical School Affiliation(s) The Commonwealth Medical College 

 Number of Residents 5 

Resources (in millions): 

 Total Medical Care Budget 

FY 2011 (through 

December 2010) 

$215.2 

Prior FY (2010) 

$210.7 

 Medical Care Expenditures $60.1 $210.1 

Total Medical Care Full-Time Employee 

Equivalents 

Workload: 

 Number of Station Level Unique 

Patients 

 Inpatient Days of Care: 

o Acute Care 

1,107.4 

26,818 

4,632 

1,125.1 

40,615 

14,700 

o Community Living 

Center/Nursing Home Care Unit 

5,829 28,179 

Hospital Discharges 786 3,373 

Total Average Daily Census (including all bed 

types) 

114 122 

Cumulative Occupancy Rate (in percent) 65.7 70.8 

Outpatient Visits 91,036 381,717 

4 All data provided by facility management. 

VA OIG Office of Healthcare Inspections 7 
CAP Review of the Wilkes-Barre VA Medical Center, Wilkes-Barre, PA 

Appendix B 

Follow-Up on Previous Recommendations 

Recommendations 

EOC 

Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

1. Comply with VHA patient safety N

standards for inspections of locked mental 

health units. 

Semi-annual inspections of locked 

mental health units are conducted 

using the VHA mental health EOC 

checklist. All deficiencies are 

addressed and tracked to resolution. 

Y 

2. Reassess the number of individuals 

needed to participate in annual respirator fit 

testing to support current infectious disease 

programs. 

Facility converted to 100 percent 

Helmet powered air-purifying respirator 

use. No annual fit test required. 

Y N 

3. Ensure designated EOC team members 

participate in all EOC rounds and that 

community based outpatient clinics are 

inspected semi-annually. 

Per facility policy, all designated EOC 

inspection team members are required 

to participate in EOC rounds and 

inspect community based outpatient 

clinics semi-annually. 

Partially Y 

4. Lock dirty utility rooms. 

QM 

Dirty utility rooms are required to be 

locked at all times. Doors have 

mechanical closers and lock 

automatically. Compliance with this 

requirement is checked bi-annually 

during EOC rounds. 

Y N 

5. Ensure the PR Committee N

documents discussion of 

recommendations for improvement in 

patient care and analyzes trends and 

findings. 

PR Committee minutes include 

discussion of system issues requiring 

improvement and analysis of trends 

identified. 

Y 

VA OIG Office of Healthcare Inspections 8 
CAP Review of the Wilkes-Barre VA Medical Center, Wilkes-Barre, PA 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

6. Improve processing times for root cause 

analyses, and implement a central QM 

database to track action items to completion. 

All root cause analyses are completed 

within the 45-day timeframe. All root 

cause analyses actions/outcome 

measures are tracked using a central 

database until completion. 

Y N 

Survey of Healthcare Experiences of 

Patients 

7. Develop and implement an action plan for 

improvement of patient satisfaction based on 

Survey of Healthcare Experiences of Patients 

data results. 

Customer service training is provided 

at new employee and annual training. 

Survey of Healthcare Experiences of 

Patients and Hospital Consumer 

Assessment of Health Providers and 

Systems data is briefed to the 

Performance Improvement and QM 

Committees and to service line 

managers, who share the information 

with their staff. 

Y N 

VA OIG Office of Healthcare Inspections 9 
CAP Review of the Wilkes-Barre VA Medical Center, Wilkes-Barre, PA 

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 

FY 2010. 

Table 1 

FY 2010 

(inpatient target = 64, outpatient target = 56) 

Inpatient 

Score 

Quarter 1 

Inpatient 

Score 

Quarter 2 

Inpatient 

Score 

Quarter 3 

Inpatient 

Score 

Quarter 4 

Outpatient 

Score 

Quarter 1 

Outpatient 

Score 

Quarter 2 

Outpatient 

Score 

Quarter 3 

Outpatient 

Score 

Quarter 4 

Facility 62.2 63.8 68.3 69.5 61.8 58.1 61.8 60.0 

VISN 62.7 65.5 65.3 63.0 59.5 61.4 60.1 61.8 

VHA 63.3 63.9 64.5 63.8 54.7 55.2 54.8 54.4 

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 10 
CAP Review of the Wilkes-Barre VA Medical Center, Wilkes-Barre, PA 

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

conditions5 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 Congestive 

Heart 

Failure 

Pneumonia Heart Attack Congestive 

Heart 

Failure 

Pneumonia 

Facility 13.50 10.57 19.06 20.49 22.67 17.07 

VHA 13.31 9.73 15.08 20.57 21.71 15.85 

5 Congestive heart failure 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 11 
CAP Review of the Wilkes-Barre VA Medical Center, Wilkes-Barre, PA 

Appendix D 

VISN Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: August 5, 2011
 

From: Director, VA Healthcare Network, VISN 4 (10N4)
 

Subject: CAP Review of the Wilkes-Barre VA Medical Center,
 

Wilkes-Barre, PA 

To:	 Director, Washington, DC, Office of Healthcare Inspections 

(54DC) 

Director, Management Review Service (VHA 10A4A4 

Management Review) 

I have reviewed the draft report of the Wilkes-Barre VA Medical Center. I 

concur with the findings and implemented plans. 

(original signed by:) 

MICHAEL A. MORELAND, FACHE 

VA OIG Office of Healthcare Inspections 12 
CAP Review of the Wilkes-Barre VA Medical Center, Wilkes-Barre, PA 

Appendix E 

Facility Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: August 1, 2011
 

From: Director, Wilkes-Barre VA Medical Center (693/00)
 

Subject: CAP Review of the Wilkes-Barre VA Medical Center,
 

Wilkes-Barre, PA 

To: Director, VA Healthcare Network, VISN 4 

Attached are comments submitted in response to the recommendations in 

the Draft Office of Inspector General Report. 

(original signed by:) 

William H. Mills 

VA OIG Office of Healthcare Inspections 13 
CAP Review of the Wilkes-Barre VA Medical Center, Wilkes-Barre, PA 

Comments to Office of Inspector General’s Report
 

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

in the Office of Inspector General report: 

OIG Recommendations 

Recommendation 1. We recommended that the identified infection prevention and
 

cleanliness deficiencies be corrected.
 

Concur
 

Each deficiency in Recommendation 1 is addressed as a separate numbered issue in
 

Facility Response below.
 

Target dates for completion:
 

05/11/2011 #1a Completed; 06/30/2011 #1b Completed; 03/31/2012 #1c & #1d.
 

05/13/2011 #2a, #2b, #2c, #2d Completed.
 

05/11/2011 #3a Completed; 05/17/2011 #3b Completed; 11/30/2011 #3c.
 

05/11/2011 #4a and #4b Completed; 11/30/2011 #4c.
 

05/27/2011 #5a Completed; 10/01/2011 #5b.
 

Facility Response:
 

Issue #1: Wheelchairs stored in Emergency area were not properly tagged to indicate
 

that cleaning was done.
 

a.	 Wheelchairs at ED entrance were cleaned and tagged according to local 

process on May 11, 2011. 

b.	 Environmental Management Service (EMS) supervisors and staff were 

reminded to adhere to the specified procedure for cleaning and tagging 

wheelchairs. 

c.	 Refresher training is conducted quarterly (June, September, December and 

March) to achieve 100% of EMS staff on the separation of clean vs. dirty 

equipment. 

d.	 Documentation of training will be maintained in EMS office. 

Issue #2: IV pumps and poles located in ED were not identified as having been cleaned 

between patient use. 

a. SPD staff provided cleaned IV pumps to the ED area on May 11, 2011. 

VA OIG Office of Healthcare Inspections 14 
CAP Review of the Wilkes-Barre VA Medical Center, Wilkes-Barre, PA 

b.	 May 12, 2011, ED staffs were instructed to place used IV pumps in the soiled 

utility room after use. 

c.	 May 13, 2011, all nursing staff in all areas were instructed to place used IV 

pumps in the soiled utility rooms after use. 

d.	 On a daily basis, SPD staff clean the IV pumps/poles placed in the soiled 

utility rooms throughout the facility. Clean IV pumps are bagged and tagged 

with date prior to being placed in the clean storage areas. 

Issue #3: Equipment not clearly marked as clean was stored in clean utility rooms. 

a.	 The equipment in question was removed immediately. Item was cleaned, 

bagged and tagged prior to return to the clean room on May 11, 2011. 

b.	 Nursing staff was educated on the process of bagging and tagging all cleaned 

equipment for the ED on May 17, 2011. 

c.	 The ED Nurse Manager monitors the clean room and reports audits monthly 

to Deputy Nurse Executive for four consecutive months. 

Issue #4: Suction devices were not unpackaged at unoccupied bedsides. 

a.	 Unpackaged suction devices were immediately removed from the area on 

May 11, 2011. 

b.	 All PACU/OR staff was educated on the proper storage of the suction devices 

at time of observation, May 11, 2011. 

c.	 OR Nurse Manager monitors the PACU daily for four consecutive months, to 

insure compliance with having the set up for emergency suctioning bagged 

and tagged to keep clean until use. 

Issue #5: Low-lying shelving units that did not allow for proper cleaning of floor under 

the shelves. 

a.	 Short Term Resolution: In all clinical areas, all items on the low-lying shelf 

have been removed and signage placed on this shelf stating “DO NOT USE 

BOTTOM SHELF.” 

b.	 Long Term Resolution: All existing shelving units will be evaluated for 

complete removal of bottom shelf which will allow for proper cleaning. Those 

shelving units that cannot be modified will be replaced with mobile wire 

shelving units with appropriate 8 inch clearance on a solid bottom shelf. 

Recommendation 2. We recommended that processes be strengthened to ensure that 

all open medications are labeled with expiration dates. 

Concur 

Target date for completion: 08/04/2011 

Facility Response: 

The open medication vial was immediately discarded. 

VA OIG Office of Healthcare Inspections 15 
CAP Review of the Wilkes-Barre VA Medical Center, Wilkes-Barre, PA 

In order to strengthen the process to ensure that all open medication vials are labeled 

with expiration dates, the following will take place: 

1.	 Nursing staff will place label on vials when opened. Label will include expiration 

date. (Pharmacy will continue to label high alert multi-dose vials.) 

2.	 Nurse Managers on each unit will monitor vials/labels monthly as a part of EOC 

rounds. 

Recommendation 3. We recommended that all required EOC team members 

consistently attend EOC rounds. 

Concur 

Target date for completion: 05/19/2011 Completed. 

Facility Response: 

Attendance was addressed immediately following the OIG-CAP Visit. The Associate 

Medical Center Director, or designee, has led all EOC Rounds from May through 

July, 2011. Attendance at EOC Rounds was discussed with all involved parties and an 

EOC Mail Group has been established for routine notification of all committee members. 

Messages are sent to the Committee Members, via the EOC Mail Group, on the 

morning of the rounds, noting time, location and a reminder that attendance is 

mandatory. 

EOC Rounds’ attendance has significantly improved with the implementation of the 

verbal and written reminders. Since May, 2011, attendance has improved to an 

averaged 96.3%. With the continuation of reminder notices, attendance is anticipated to 

remain steady. 

Recommendation 4. We recommended that processes be strengthened to ensure 

that competency documents contain all required signatures and dates. 

Concur 

Each deficiency in Recommendation 4 is addressed as a separate numbered issue in 

Facility Response below. 

Target date for completion: 08/04/2011 (#1, #2, and #3) and 11/30/2011 (#4). 

Facility Response: 

The 3 competency files with missing signatures and dates were immediately corrected 

and placed in employee personnel file. 

In order to strengthen the process to ensure competency documents contain all 

required signatures and dates, the following action will take place: 

VA OIG Office of Healthcare Inspections 16 
CAP Review of the Wilkes-Barre VA Medical Center, Wilkes-Barre, PA 

1.	 Nurse Managers will be re-educated on completion of competency forms. 

2.	 Nurse Managers will review competency form prior to submission for Nurse 

Executive/Deputy Nurse Executive signatures to ensure dates and signatures are 

present. 

3.	 Nurse Executive/Deputy Nurse Executive will review competency forms for 

completeness prior to placement in employee files. 

4.	 Random audits will be completed by Patient Support Assistant and Timekeeper 

for Nursing Service, for four consecutive months. 

Recommendation 5. We recommended that moderate sedation documentation 

include all required elements and that supervisors monitor compliance. 

Concur 

Each deficiency in Recommendation 5 is addressed as a separate numbered issue in 

Facility Response below. 

Target date for completion: 08/31/2011 (#1, #2, and #3) and 12/31/2011 (#4). 

Facility Response: 

1.	 Medical Center policy will be revised to include assessment of airway, review of 

organ systems and assessment of risk. 

2.	 The moderate sedation template will be amended to include these elements as 

required fields. 

3.	 Once the policy is approved and the template changed, providers will be 

educated on the revised requirements. 

4.	 With implementation of changes, the Medical Records Committee will monitor 

compliance with documentation of assessment of airway, review of organ 

systems and assessment of risk. Outcomes will be reported as a performance 

improvement indicator to Surgical Service. Monitoring will be continued until 

overall monthly sustained compliance is 100% for four consecutive months, 

following implementation of policy. 

Recommendation 6. We recommended that the Director approve all PR extensions in 

writing. 

Concur 

Target date for completion: 07/26/11 Completed. 

Facility Response: 

Peer Review Committee has revised ‘Request for Extension’ letter for Director’s 

signature which was implemented July 26, 2011. 

Peer Review Committee created spreadsheet for on-going tracking which was 

implemented July 26, 2011. 

VA OIG Office of Healthcare Inspections 17 
CAP Review of the Wilkes-Barre VA Medical Center, Wilkes-Barre, PA 

Recommendation 7. We recommended that processes be strengthened to ensure 

that advance directive screening is accurate and that patients’ hard copy advance 

directives are scanned into the electronic medical record. 

Concur 

Target date for completion: 08/15/2011(#1 and #2) and 12/31/2011 (#3). 

Facility Response: 

All patients admitted to the WBVAMC are asked, as part of the initial Nursing 

Assessment, “Do you have an Advanced Directive?” If the answer is yes then the 

patient is asked to provide a copy of the document. Upon receipt of the document it is 

sent to Medical Records for scanning into the medical record. A note titled “Advance 

Directive,” is placed in the medical record and the presence of an Advance Directive is 

included in the Crises, Warnings, Allergies and/or Adverse Reactions and Directives 

(CWAD) posting section of the medical record. 

If the patient indicates that he does not have an advance directive, he is then asked if 

he would like more information about creating one. If the patient indicates no, then this 

information is documented in a note titled “Advance Directive Discussion”. 

If the patient indicates he would like more information, or that he/she would like to 

develop an Advance Directive, then a consult is placed with Social Work Service 

requesting follow-up. Designated Social Worker will provide patient with requested 

information and any other assistance necessary. When the discussion results in the 

patient completing an advance directive, the advance directive must be filed or scanned 

with a progress note titled “Advance Directive.” Documentation of the discussion that 

led to the filing of an advance directive can be in the form of an addendum to the 

“Advance Directive” note associated with that advance directive or in a separate note 

titled “Advance Directive Discussion.” The presence of an Advance Directive is 

included in the Crises, Warnings, Allergies and/or Adverse Reactions and Directives 

(CWAD) posting section of the medical record. 

1.	 The Chief of Social Work Service ensures that advance directive screenings are 

accurate and completed by providing education and policy to staff. 

2.	 The Chief of Social Work Service ensures that advance directive documents are 

scanned into the electronic medical record, by providing education and policy to 

staff. 

3.	 The Chief of Social Work assures compliance with policy by conducting a record 

review of all medical center admissions for a four month period beginning on 

September 11, 2011 and continuing through December 31, 2011. 

VA OIG Office of Healthcare Inspections 18 
CAP Review of the Wilkes-Barre VA Medical Center, Wilkes-Barre, PA 

Appendix F 

OIG Contact and Staff Acknowledgments 

Contact For more information about this report, please contact the 

Office of Inspector General at (202) 461-4720 

Contributors Donna Giroux, RN, Project Leader 

Bruce Barnes, Team Leader 

Myra Conway, RN 

Katharine Foster, RN 

Kathy Gudgell, RN, JD 

Natalie Sadow-Colón, MBA, Program Support Assistant 

Gerard Poto, Special Agent, Office of Investigations 

VA OIG Office of Healthcare Inspections 19 
CAP Review of the Wilkes-Barre VA Medical Center, Wilkes-Barre, PA 

Appendix G 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VISN 4 VA Healthcare Network (10N4) 

Director, Wilkes-Barre VA Medical Center (693/00) 

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: Robert P. Casey, Jr.; Patrick J. Toomey 

U.S. House of Representatives: Lou Barletta, Charles W. Dent, Tim Holden, 

Tom Marino 

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

VA OIG Office of Healthcare Inspections 20