Office of Healthcare Inspections 

Department of Veterans Affairs 

Office of Inspector General 

Report No. 08-02604-214 

Combined Assessment Program 

Review of the 

Iowa City VA Medical Center 

Iowa City, Iowa 

September 16, 2009 

Washington, DC 20420 
Why We Did This Review 

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

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

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

of Healthcare Inspections and Investigations to provide collaborative assessments of 

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

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

convenient access to high quality medical services. 

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

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

to the OIG. 

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

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

To Report Suspected Wrongdoing in VA Programs and Operations 

Call the OIG Hotline – (800) 488-8244 
Combined Assessment Program Review of the Iowa City VA Medical Center, Iowa City, Iowa 

Table of Contents 

Page 

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

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

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

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

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

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

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

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

Environment of Care.......................................................................................... 6
 

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

Medication Management ................................................................................... 9
 

Suicide Prevention Program.............................................................................. 10
 

Emergency/Urgent Care Operations ................................................................. 11
 

Follow-Up on VA Community Nursing Home Program ...................................... 13
 

Review Activity Without Recommendations............................................................ 14
 

Survey of Healthcare Experiences of Patients .................................................. 14
 

Appendixes 

A. Acting VISN Director Comments ....................................................................... 17
 

B. Medical Center Director Comments................................................................... 18
 

C. OIG Contact and Staff Acknowledgments ......................................................... 24
 

D. Report Distribution............................................................................................. 25
 

VA Office of Inspector General 
Combined Assessment Program Review of the Iowa City VA Medical Center, Iowa City, Iowa 

Executive Summary 

Introduction 

Results of the 

Review 

During the week of June 15–19, 2009, the OIG conducted a 

Combined Assessment Program (CAP) review of the Iowa 

City VA Medical Center (the medical center), Iowa City, IA. 

The purpose of the review was to evaluate selected 

operations, focusing on patient care administration and 

quality management (QM). During the review, we also 

provided fraud and integrity awareness training to 29 medical 

center employees. The medical center is part of Veterans 

Integrated Service Network (VISN) 23. 

The CAP review covered seven operational activities and 

one follow-up review area. We identified the following 

organizational strength and reported accomplishment: 

•	 Special programs provide therapeutic benefits. 

We made recommendations in six of the activities reviewed 

and in the follow-up review area. (One environment of care 

(EOC) recommendation was a repeat recommendation from 

our prior CAP report.) For these six activities and the 

follow-up review area, the medical center needed to assure 

that: 

•	 Clinical privileges granted to contractors do not extend 

beyond the contract period. 

•	 Credentialing and privileging (C&P) documentation is 

maintained in accordance with Veterans Health 

Administration (VHA) policy. 

•	 Supervisors provide written notification of completed peer 

review (PR) actions to the Peer Review Committee (PRC) 

and that committee minutes reflect actions taken. 

•	 Clinical disclosure of adverse events is conducted and 

documented in accordance with VHA policy. 

•	 Identified safety deficiencies are corrected. 

•	 Identified patient privacy deficiencies are corrected. 

•	 Locked mental health (MH) unit staff and Multidisciplinary 

Safety Inspection Team (MSIT) members receive 

environmental hazards training, as required by VHA. 

•	 Patient discharge summaries include active outpatient 

medications. 

VA Office of Inspector General i 
Combined Assessment Program Review of the Iowa City VA Medical Center, Iowa City, Iowa 

•	 Proper medication disposition is initiated for medications 

brought into the medical center by MH patients. 

•	 Documentation of Suicide Prevention Coordinator (SPC) 

and MH provider collaboration for patients deemed at high 

risk for suicide is in compliance with VHA regulations. 

•	 Emergency Department (ED) staff complete all inter-facility 

transfer documentation in accordance with VHA policy. 

•	 Processes are defined to ensure effective hand-off 

communications when ED patients are admitted to 

inpatient units in the medical center. 

•	 ED managers complete competency assessments in 

accordance with medical center policy. 

•	 Community nursing home (CNH) patients receive follow-up 

visits and monitoring in accordance with VHA policy. 

The medical center complied with selected standards in the 

following activity: 

•	 Survey of Healthcare Experiences of Patients (SHEP). 

This report was prepared under the direction of 

Verena Briley-Hudson, Director, Chicago and Kansas City 

Offices of Healthcare Inspections. 

Comments The Acting VISN and Medical Center Directors agreed with 

the CAP review findings and recommendations and provided 

acceptable improvement plans. (See Appendixes A and B, 

pages 17–23 for full text of the Directors’ comments.) We 

will follow up on the planned actions until they are 

completed. 

 (original signed by:)

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

 Assistant Inspector General for

 Healthcare Inspections 


 

VA Office of Inspector General ii 
Combined Assessment Program Review of the Iowa City VA Medical Center, Iowa City, Iowa 

Introduction 

Profile Organization. The medical center is located in Iowa City, 

IA, and provides a broad range of inpatient and outpatient 

health care services. Outpatient care is also provided at a 

satellite clinic in Coralville, IA, and at five community based 

outpatient clinics (CBOCs) in Bettendorf, Dubuque, and 

Waterloo, IA, and in Galesburg and Quincy, IL. The medical 

center is part of VISN 23 and serves a veteran population of 

about 184,000 throughout eastern Iowa and western Illinois. 

Programs. The medical center provides primary care, 

specialty care, MH services, extended care and 

rehabilitation, and social work services. Additional programs 

focus on Operation Iraqi Freedom/Operation Enduring 

Freedom and women veterans. The medical center has 

93 hospital beds. 

Affiliations and Research. The medical center is affiliated 

with the University of Iowa’s Carver College of Medicine and 

provides training for 97 residents. It also provides training in 

other health professions, including nursing, pharmacy, 

dentistry, social work, audiology, clinical laboratory science, 

and psychology. 

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

program had 51 VA-funded projects, 200 active research 

protocols, and a budget of $11 million from the VA and 

$24.5 million from external sources. Important areas of 

research included the biology of inflammation, diabetic 

vascular disease, cancer, immunology, health services, 

rehabilitation, glaucoma and other visual problems, traumatic 

brain injury, and post-traumatic stress disorder. 

Resources. In FY 2008, medical care expenditures totaled 

$213.8 million. The FY 2009 medical care budget is 

$218.7 million. FY 2008 staffing was 1,220 full-time 

employee equivalents (FTE), including 83 physicians, 

13 physician assistants, 16 nurse practitioners, and 

229 nurses. 

Workload. In FY 2008, the medical center treated 

40,541 unique patients and provided 18,803 inpatient days in 

the hospital. The inpatient care workload totaled 

3,380 discharges, and the average daily census was 51. 

Outpatient workload totaled 238,862 visits. 

VA Office of Inspector General 1 
Combined Assessment Program Review of the Iowa City VA Medical Center, Iowa City, Iowa 

Objectives and 

Scope 

Objectives. CAP reviews are one element of the OIG’s 

efforts to ensure that our Nation’s veterans receive high 

quality VA health care services. The objectives of the CAP 

review are to: 

•	 Conduct recurring evaluations of selected health care 

facility operations, focusing on patient care administration 

and QM. 

•	 Provide fraud and integrity awareness training to increase 

employee understanding of the potential for program 

fraud and the requirement to refer suspected criminal 

activity to the OIG. 

Scope. We reviewed selected clinical and administrative 

activities to evaluate the effectiveness of patient care 

administration and QM. Patient care administration is the 

process of planning and delivering patient care. QM is the 

process of monitoring the quality of care to identify and 

correct harmful and potentially harmful practices and 

conditions. 

In performing the review, we inspected work areas; 

interviewed managers and employees; and reviewed clinical 

and administrative records. The review covered the 

following seven activities and one follow-up review area: 

•	 Coordination of Care. 

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

•	 EOC. 

•	 Follow-Up on VA CNH Program. 

•	 Medication Management. 

•	 QM Program. 

•	 SHEP. 

•	 Suicide Prevention Program. 

The review covered medical center operations for FY 2008 

and FY 2009 through June 12, 2009, and was done in 

accordance with OIG standard operating procedures for CAP 

reviews. We also followed up on selected recommendations 

from our prior CAP review of the medical center (Combined 

Assessment Program Review of the VA Iowa City Health 

Care System, Iowa City, Iowa, Report No. 06-01602-219, 

VA Office of Inspector General 2 
Combined Assessment Program Review of the Iowa City VA Medical Center, Iowa City, Iowa 

September 25, 2006). We had repeat findings from our prior 

CAP review in EOC and in the follow-up review area. 

During this review, we also presented fraud and integrity 

awareness briefings for 29 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. The activity in the “Review Activity 

Without Recommendations” section had no reportable 

findings. 

Organizational Strength 

Golf for Veterans Everywhere (GIVE) is a partnership 

between the Riverside Blue Top Golf Course, the Iowa 

Section of the Professional Golfers’ Association, and the 

medical center. The program is rehabilitative in nature, 

providing golf instruction and socialization for veterans who 

suffer from post-traumatic stress disorder, traumatic brain 

injury, and other medical or MH conditions. It has educated 

the public to the challenges faced by veterans in their local 

communities and has been featured in local and national 

media. The program is provided at no cost, and class size 

averages 15–20 veterans. The fifth class will be completed 

during 2009. 

The TEE (training, experience, and exposure) Tournament is 

an annual event that uses a therapeutic format to provide 

veterans with an opportunity to develop new skills and 

strengthen self-esteem through participation in adaptive golf 

and bowling. The medical center has hosted this event for 

visually impaired veterans for the past 15 years, and due to 

the program’s success and the efforts of the GIVE partners, 

the event is now recognized as one of six VA national 

rehabilitation special events. 

Special Programs 

Provide 

Therapeutic 

Benefits 

VA Office of Inspector General 3 
 

 

Combined Assessment Program Review of the Iowa City VA Medical Center, Iowa City, Iowa 

Results 

Review Activities With Recommendations 

Quality 

Management 

Program 

The purpose of this review was to evaluate whether the 

medical center had a comprehensive and effective QM 

program designed to monitor patient care activities and 

coordinate improvement efforts and whether senior 

managers actively supported the program’s activities. We 

interviewed senior managers, the Quality and Performance 

Improvement (PI) Program Manager, and key staff. We 

evaluated policies, PI data, and other relevant documents. 

The QM program was generally effective in providing 

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

managers supported the program through participation in 

and evaluation of PI initiatives and through allocation of 

resources to the program. Appropriate review structures 

were in place for 11 of the 14 program activities reviewed. 

We identified three areas that needed improvement. 

C&P. VHA policy1 requires that clinical privileges be granted 

for a period not to exceed 2 years and that privileges granted 

to contractors do not extend beyond the contract period. We 

reviewed the C&P folders and corresponding contracts of 

nine contractors who had been privileged or reprivileged 

during the past 12 months. All nine contractors had been 

granted clinical privileges that extended beyond the contract 

period. 

VHA policy also requires that service chiefs review all C&P 

information and document the review. Requirements include 

listing the documents reviewed and providing the rationale 

for conclusions. We reviewed the C&P folders and physician 

profiles for 14 physicians who had been initially privileged or 

reprivileged during the past 12 months and found that the 

documentation did not fully address the information reviewed 

and the rationale for the conclusions. Additionally, the 

privileging decision of the medical staff’s Executive 

Committee must be documented, and the minutes must 

reflect the documents reviewed and the rationale for the 

stated conclusion. We found that committee minutes 

reflected the documents reviewed and the rationale for the 

decision for only 2 (14 percent) of the 14 physicians. 

1

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

VA Office of Inspector General 4 
 

Combined Assessment Program Review of the Iowa City VA Medical Center, Iowa City, Iowa 

Recommendation 1 

Recommendation 2 

PR. When a final Level 2 or 3 is assigned to a PR by the 

PRC, VHA policy2 requires that the provider’s supervisor 

communicate with the provider and assure that appropriate 

non-disciplinary, non-punitive action is implemented. The 

supervisor is to provide written notification, which contains 

feedback on the completed action, to the PRC. We found 

that supervisors had not provided written notification to the 

PRC. 

Adverse Event Disclosure. VHA policy3 requires that clinical 

disclosures of significant adverse events be documented in 

the electronic medical record. We requested documentation 

of clinical disclosure for adverse events that occurred from 

June 2008 through May 2009. The medical center did not 

maintain a log of clinical disclosures and was unable to 

provide medical record documentation. 

We recommended that the Acting VISN Director ensure that 

the Medical Center Director requires that clinical privileges 

granted to contractors do not extend beyond the contract 

period. 

The Acting VISN and Medical Center Directors agreed with 

the finding and recommendation. The C&P Coordinator has 

a list of all sharing agreements and associated expiration 

dates. As contract physicians’ privileges become due for 

renewal, the privileges granted will not extend beyond the 

contract period. The corrective actions are acceptable, and 

we consider this recommendation closed. 

We recommended that the Acting VISN Director ensure that 

the Medical Center Director requires that C&P 

documentation is maintained in accordance with VHA policy. 

The Acting VISN and Medical Center Directors agreed with 

the findings and recommendation. Since April 2009, the 

privileging decisions of the Provider Staff Evaluation and 

Credentialing Subcommittee have been appropriately 

documented. Minutes reflect that documents have been 

reviewed and also reflect the rationale for the stated 

conclusions. The corrective actions are acceptable, and we 

consider this recommendation closed. 

2

 VHA Directive 2008-004, Peer Review for Quality Management, January 28, 2008. 3

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

VA Office of Inspector General 5 
Combined Assessment Program Review of the Iowa City VA Medical Center, Iowa City, Iowa 

Recommendation 3 

Recommendation 4 

Environment of 

Care 

We recommended that the Acting VISN Director ensure that 

the Medical Center Director requires that supervisors provide 

written notification of completed PR actions to the PRC and 

that committee minutes reflect actions taken. 

The Acting VISN and Medical Center Directors agreed with 

the finding and recommendation. The Risk Manager has 

developed a form for use when the PR Advisory Group 

(PRAG) has assigned a final Level of 2 or 3 to a case. This 

form is completed by the service chief, who speaks with the 

involved provider, provides education/counseling about the 

issue involved, and documents any other follow-up. The 

form is noted in the next PRAG meeting minutes as written 

follow-up for a PR recommendation and is permanently filed 

in the PR case folder. The corrective actions are acceptable, 

and we consider this recommendation closed. 

We recommended that the Acting VISN Director ensure that 

the Medical Center Director requires that clinical disclosure 

of adverse events is conducted and documented in 

accordance with VHA policy. 

The Acting VISN and Medical Center Directors agreed with 

the finding and recommendation. A Computerized Patient 

Record System (CPRS) template is being developed for 

clinical disclosure of adverse events. All clinical disclosures 

will be documented using this template and will be tracked 

by Patient Safety and Quality Improvement. The 

implementation plans are acceptable, and we will follow up 

on the planned actions until they are completed. 

The purpose of this review was to determine if the medical 

center complied with selected infection control (IC) standards 

and maintained a safe and clean patient care environment. 

VHA facilities are required to establish a comprehensive 

EOC program that fully meets VA National Center for Patient 

Safety, Occupational Safety and Health Administration, and 

Joint Commission (JC) standards. 

We inspected the inpatient medical unit (5E), the surgical 

unit (5W), the locked MH unit (9E), the telemetry unit (7E), 

the intensive care unit (ICU), the dialysis unit, the eye clinic, 

and primary care clinics. 

We evaluated the IC program to determine compliance with 

VHA directives. IC staff appropriately collected, trended, and 

analyzed data related to infections, and they involved 

VA Office of Inspector General 6 
Combined Assessment Program Review of the Iowa City VA Medical Center, Iowa City, Iowa 

clinicians in improvement initiatives to reduce infection risks 

for patients and staff. IC staff also provided in-service 

education as new health concerns were identified. 

We also followed up on recommendations from our prior 

CAP review and identified unsecured sharp items and 

unsecured cleaning products as repeat findings. (See 

below.) 

The medical center was generally clean and effectively 

maintained. Nurse managers and unit staff expressed 

satisfaction with the responsiveness of the housekeeping 

staff on their units. We identified the following areas that 

needed improvement. 

Safety. Medications and cleaning products must be secured 

when not in use. Bags of intravenous fluids were stored in 

an unlocked room and under the kitchenette sink on the 

surgical unit. We found an unlocked medication cart in the 

hallway on the medical unit. Unsecured medications were 

also found in the ICU men’s staff locker room and on a 

desktop in the eye clinic. Unsecured cleaning products were 

found in a men’s restroom on the surgical unit, in the soiled 

utility rooms on the medical unit and in the ED, and in the 

eye clinic. 

Sharp items must be secured from public access. We found 

unsecured sharp items in the medical unit’s soiled utility 

room, in the dialysis unit’s clean utility room and isolation 

room, and in an unlocked cart located in the center of the 

dialysis unit. In the ICU, we found scissors and knives in the 

unlocked staff break room and sharp items in the unlocked 

anteroom and in unlocked treatment carts. On the surgical 

unit, we noted unsecured respiratory supplies that included 

sharp items. We also found unsecured sharp items in the 

primary care clinics. 

Patient Privacy. Federal law requires the protection of 

sensitive patient information. A computer with an active 

screen was left unattended in the ICU, leaving the patient’s 

name, social security number, date of birth, and health 

information accessible. In the eye clinic, an unsecured 

computer with digital camera imaging capability was not 

properly logged off. 

Environmental Hazards Training. VHA requires that all staff 

who work on locked MH units and members of the MSIT 

VA Office of Inspector General 7 
 

Combined Assessment Program Review of the Iowa City VA Medical Center, Iowa City, Iowa 

receive training on the environmental hazards that represent 

a threat to suicidal patients.4 We reviewed position-specific 

competency assessment checklists for 26 locked MH unit 

employees and noted that 23 (88 percent) had not received 

this training. Additionally, MSIT members were also lacking 

this training. 

Recommendation 5 We recommended that the Acting VISN Director ensure that 

the Medical Center Director requires that identified safety 

deficiencies are corrected. 

The Acting VISN and Medical Center Directors agreed with 

the findings and recommendation. A section has been 

added to JC Readiness Rounds regarding security of 

medications, sharps, respiratory supplies, and cleaning 

products. New supply carts have been ordered for the ICU 

unit. Managers are currently reviewing all clinical areas to 

ensure compliance. The implementation plans are 

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

they are completed. 

Recommendation 6 We recommended that the Acting VISN Director ensure that 

the Medical Center Director requires that identified patient 

privacy deficiencies are corrected. 

The Acting VISN and Medical Center Directors agreed with 

the findings and recommendation. The Privacy Officer and 

Information Security Officer conduct weekly EOC rounds to 

check for privacy and information security violations. They 

have increased awareness by educating staff on privacy and 

information security policies. All employees, volunteers, and 

contractors are required to complete privacy and information 

security training annually and to comply with medical center 

policy. The corrective actions are acceptable, and we 

consider this recommendation closed. 

Recommendation 7 We recommended that the Acting VISN Director ensure that 

the Medical Center Director requires that locked MH unit 

staff and MSIT members receive environmental hazards 

training, as required by VHA. 

The Acting VISN and Medical Center Directors agreed with 

the findings and recommendation. All locked MH unit staff 

and MSIT members will complete training. Training will be 

4

 Deputy Under Secretary for Health for Operations and Management, “Mental Health Environment of Care 

Checklist,” memorandum to Network Directors, August 27, 2007. 

VA Office of Inspector General 8 
 

Combined Assessment Program Review of the Iowa City VA Medical Center, Iowa City, Iowa 

Coordination of 

Care 

Recommendation 8 

Medication 

Management 

reflected on annual competency assessments. The 

implementation plans are acceptable, and we will follow up 

on the planned actions until they are completed. 

The purpose of this review was to evaluate whether 

consultations, intra-facility transfers, and discharges were 

coordinated appropriately over the continuum of care and 

met VHA and JC requirements. Coordinated consultations, 

transfers, and discharges are essential to optimal patient 

outcomes. 

We reviewed consultations, discharges, and intra-facility 

transfer documentation for three patients per bed service 

(medicine, surgery, and MH). We determined that clinicians 

appropriately managed patient consultations and intra-facility 

transfers in accordance with medical center policy. We 

identified one area that needed improvement. 

Discharges. VHA policy5

 requires the provider to document 

in the discharge summary those medications that the patient 

should take after being discharged from the facility. For the 

three surgical unit patients whose records we reviewed, we 

identified that providers did not include all active outpatient 

medications in the patients’ discharge summaries. 

We recommended that the Acting VISN Director ensure that 

the Medical Center Director requires that patient discharge 

summaries include active outpatient medications. 

The Acting VISN and Medical Center Directors agreed with 

the finding and recommendation. The Chief of Staff has 

requested that the Surgical Specialty Service Line ensure 

that all active outpatient medications are included in surgery 

discharge summaries. Monthly medical record audits will be 

completed by the service line to ensure compliance. The 

implementation plans are acceptable, and we will follow up 

on the planned actions until they are completed. 

The purpose of this review was to evaluate whether the 

medical center had adequate medication management 

practices. A safe medication management system includes 

medication ordering, administering, and monitoring. 

We reviewed selected medication management processes 

for three inpatient units. We found appropriate use of patient 

5

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

VA Office of Inspector General 9 
 

Combined Assessment Program Review of the Iowa City VA Medical Center, Iowa City, Iowa 

Recommendation 9 

Suicide Prevention 

Program 

armbands to correctly identify patients prior to medication 

administration. We identified one area that needed 

improvement. 

Medication Disposition Upon Admission. Medical center 

policy requires that medications brought into the facility by a 

patient be identified by the physician and, whenever 

possible, returned to family members or mailed back to the 

patient’s residence. During our inspection of the locked MH 

unit, we found patient medications brought from patients’ 

homes stored in the medication room. We also found 

medications belonging to a discharged patient stored in this 

area. Additionally, we found controlled substances stored in 

a locked cabinet in the medication room with other patient 

personal belongings. This storage of patient medications is 

contrary to medical center policy. Staff expressed concerns 

regarding medication disposition challenges for the MH 

patient population. 

We recommended that the Acting VISN Director ensure that 

the Medical Center Director requires the proper disposition of 

medications brought into the medical center by MH patients. 

The Acting VISN and Medical Center Directors agreed with 

the findings and recommendation. All patient medications 

brought into the medical center are being sent home with 

family members or mailed to the patients’ homes. 

Medications for homeless patients are being stored in the 

outpatient pharmacy until the patients are discharged. Daily 

checks are performed to ensure that no patient medications 

are kept on the unit. The corrective actions are acceptable, 

and we consider this recommendation closed. 

The purpose of this review was to determine whether VHA 

health care facilities had implemented suicide prevention 

programs that were in compliance with VHA regulations.6 

We assessed whether senior managers had appointed SPCs 

at facilities and very large CBOCs,7 and we evaluated 

whether SPCs fulfilled all required functions. Also, we 

verified whether medical records of patients determined to 

be at high risk for suicide contained Category II Patient 

Record Flags (PRFs),8 documented safety plans that 

6

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

September 11, 2008. 

7

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

8

 A Category II PRF is an alert mechanism that is displayed prominently in medical records. 

VA Office of Inspector General 10 
Combined Assessment Program Review of the Iowa City VA Medical Center, Iowa City, Iowa 

Recommendation 10 

Emergency/Urgent 

Care Operations 

addressed suicidality, and documented collaboration 

between MH providers and SPCs. 

We interviewed the medical center’s SPCs and a MH 

provider, and we reviewed pertinent policies. We reviewed 

the medical records of seven medical center patients and 

three CBOC patients determined to be at high risk for 

suicide. All 10 records contained the required PRFs and 

safety plans. We identified one area that needed 

improvement. 

Collaboration Between SPCs and MH Providers. Three 

(30 percent) of the 10 medical records did not show clear 

evidence of collaboration between the SPCs and MH 

providers. 

We recommended that the Acting VISN Director ensure that 

the Medical Center Director requires compliance with VHA 

regulations regarding documentation of SPC and MH 

provider collaboration for patients deemed at high risk for 

suicide. 

The Acting VISN and Medical Center Directors agreed with 

the finding and recommendation. Patients at high risk for 

suicide are identified by the treatment team, and a note is 

entered in CPRS by the SPC. Members of the treatment 

team have been added as additional signers of this progress 

note, and concurrence is noted by their electronic signature. 

An audit of patients flagged in the past 6 months shows 

100 percent compliance with treatment team documentation. 

The corrective actions are acceptable, and we consider this 

recommendation closed. 

The purpose of this review was to evaluate whether the 

medical center’s ED complied with VHA guidelines related to 

hours of operation, clinical services, consultations, transfers, 

staffing, and staff competencies. In addition, we inspected 

the ED physical environment for cleanliness and safety. 

The ED is located in the main hospital and operates 

24 hours a day, 7 days a week, as required for ED 

designation. Emergency services provided are within the 

medical center’s patient care capabilities, and a policy is in 

place for managing patients whose care exceeds the 

medical center’s capability. We identified three areas that 

needed improvement. 

VA Office of Inspector General 11 
 

Combined Assessment Program Review of the Iowa City VA Medical Center, Iowa City, Iowa 

Inter-Facility Transfers. We reviewed the medical records of 

three patients transferred from the ED to other facilities. ED 

staff did not comply with VHA regulations9

 and local policy 

for inter-facility transfers, which require completion of all 

necessary documentation prior to patient transfer. In all 

three records reviewed, staff failed to document patient 

eligibility information, reason for transfer, type and level of 

services required, consent, and condition on transfer. 

Admissions. We reviewed five medical records of ED 

patients who were admitted to an inpatient unit within the 

medical center. None of these records showed evidence of 

registered nurse (RN) hand-off communication. Two weeks 

prior to our site visit, ED managers created a process for 

nursing hand-off; however, the records we reviewed lacked 

sufficient documentation. 

Competency Assessment. Medical center policy requires 

that competency assessments be conducted annually. We 

reviewed three ED RN competency folders, and all lacked 

current assessments. For two RNs, managers were 

delinquent with the previous year of competency 

assessments; the third RN lacked 2 years of assessments. 

Recommendation 11 We recommended that the Acting VISN Director ensure that 

the Medical Center Director requires that ED staff complete 

all inter-facility transfer documentation in accordance with 

VHA policy. 

The Acting VISN and Medical Center Directors agreed with 

the findings and recommendation. A multidisciplinary 

workgroup has reviewed VHA policy and is completing an 

electronic progress note template that will meet 

requirements. ED staff will complete all inter-facility transfer 

documentation in accordance with VHA policy, and monthly 

audits will be conducted to ensure compliance. The 

implementation plans are acceptable, and we will follow up 

on the planned actions until they are completed. 

Recommendation 12 We recommended that the Acting VISN Director ensure that 

the Medical Center Director defines processes to ensure 

effective hand-off communications when ED patients are 

admitted to inpatient units in the medical center. 

9

 VHA Directive 2007-015, Inter-Facility Transfer Policy, May 7, 2007. 

VA Office of Inspector General 12 
 

 

Combined Assessment Program Review of the Iowa City VA Medical Center, Iowa City, Iowa 

Recommendation 13 

Follow-Up on VA 

Community 

Nursing Home 

Program 

The Acting VISN and Medical Center Directors agreed with 

the finding and recommendation. A template was developed 

and has been implemented. The medical center’s policy on 

hand-off communications will be updated to reflect changes 

to the process. The implementation plans are acceptable, 

and we will follow up on the planned actions until they are 

completed. 

We recommended that the Acting VISN Director ensure that 

the Medical Center Director requires that ED managers 

complete competency assessments in accordance with 

medical center policy. 

The Acting VISN and Medical Center Directors agreed with 

the findings and recommendation. ED staff have been 

educated, and competencies have been completed in 

accordance with the annual review requirement. The 

corrective actions are acceptable, and we consider this 

recommendation closed. 

As a follow-up to a recommendation from our prior CAP 

review, we reassessed the medical center’s compliance with 

selected requirements in VHA policy10 regarding monitoring 

of and follow-up visits for patients placed in VA contract 

CNHs. In addition, we reexamined CNH oversight 

committee membership and the reporting process to clinical 

leadership to assess compliance with VHA policy. 

The medical center had completed one of the corrective 

actions from the previous CAP review by appointing a 

medical staff representative to the CNH/Adult Day Health 

Care Committee. This committee reports CNH oversight 

activities to the Clinical Executive Board. We identified one 

area that continued to require management attention. 

Follow-Up Visits. We reviewed the medical records of 

12 CNH patients. Eight (67 percent) of these patients did not 

have documentation in their medical records of follow-up 

visits and/or monthly monitoring by an RN. The medical 

center’s action plan in response to our prior CAP review was 

to add a 0.5 FTE RN to the CNH program. We found that 

this action had not been completed. The CNH Program had 

no RN FTE assigned. Rather, the Community Health RN 

was instructed to perform CNH patient visits and monitoring 

as a collateral duty. As a result, documentation of follow-up 

10 VHA Handbook 1143.2, VHA Community Nursing Home Oversight Procedures, June 4, 2004. 

VA Office of Inspector General 13 
Combined Assessment Program Review of the Iowa City VA Medical Center, Iowa City, Iowa 

visits and monitoring were not being accomplished in 

accordance with VHA policy. 

Recommendation 14 We recommended that the Acting VISN Director ensure that 

the Medical Center Director requires that CNH patients 

receive follow-up visits and monitoring in accordance with 

VHA policy. 

The Acting VISN and Medical Center Directors agreed with 

the findings and recommendation. The Community Health 

RN assigned to do follow-up visits and monitoring is 

assigned to the CNH program as a 0.5 FTE. The 

organizational chart has been changed to reflect this. The 

Community Health RN will be instructed to complete review 

notes in a more accurate and timely manner; other duties 

have been reduced to allow time to complete visits and 

documentation. Compliance with completion of 

documentation will be monitored monthly. The 

implementation plans are acceptable, and we will follow up 

on the planned actions until they are completed. 

Review Activity Without Recommendations 

Survey of 

Healthcare 

Experiences of 

Patients 

The purpose of this review was to assess the extent that the 

medical center used quarterly SHEP results to improve 

patient care, treatment, and services. The Performance 

Analysis Center for Excellence of the Office of Quality and 

Performance within VHA is the analytical, methodological, 

and reporting staff for SHEP. VHA set performance 

measure results for patients reporting overall satisfaction of 

“very good” or “excellent” at 76 percent for inpatients and 

77 percent for outpatients. 

Figures 1 and 2 on the next page show the medical center’s 

SHEP performance measure results for inpatients and 

outpatients, respectively. 

VA Office of Inspector General 14 
Combined Assessment Program Review of the Iowa City VA Medical Center, Iowa City, Iowa 

VA Office of Inspector General 15 
Combined Assessment Program Review of the Iowa City VA Medical Center, Iowa City, Iowa 

We reviewed survey results for FYs 2007 and 2008. The 

medical center’s inpatient results exceeded the target in all 

8 quarters. The medical center’s outpatient results met or 

exceeded the target in all 8 quarters reviewed. Managers 

had analyzed survey results, identified opportunities for 

improvement, and initiated actions when appropriate. 

Effective October 1, 2008, VHA changed to a new survey 

process. The medical center’s 1st quarter FY 2009 inpatient 

data exceeded the targets. We made no recommendations. 

VA Office of Inspector General 16 
Combined Assessment Program Review of the Iowa City VA Medical Center, Iowa City, Iowa 

Appendix A 

Acting VISN Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: August 25, 2009 

From: Acting Director, VA Midwest Health Care Network (10N23) 

Subject: Combined Assessment Program Review of the Iowa City 

VA Medical Center, Iowa City, Iowa 

To: Director, Chicago and Kansas City Offices of Healthcare 

Inspections (54CH/54KC) 

Director, Management Review Service (10B5) 

Concur with the action plans regarding the findings and recommendations 

in this report. 

CYNTHIA BREYFOGLE, FACHE 

VA Office of Inspector General 17 
Combined Assessment Program Review of the Iowa City VA Medical Center, Iowa City, Iowa 

Appendix B 

Medical Center Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: August 25, 2009 

From: Director, Iowa City VA Medical Center (636A8/00) 

Subject: Combined Assessment Program Review of the Iowa City 

VA Medical Center, Iowa City, Iowa 

To: Acting Director, VA Midwest Health Care Network (10N23) 

The purpose of this memorandum is to forward our comments to the 

Combined Assessment Program review conducted at this facility on June 

15-19, 2009. If you have any questions, please contact me directly at 

319-339-7100. 

(original signed by:) 

BARRY D. SHARP 

VA Office of Inspector General 18 
 

 

 

Combined Assessment Program Review of the Iowa City VA Medical Center, Iowa City, Iowa 

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 Acting VISN Director 

ensure that the Medical Center Director requires that clinical privileges 

granted to contractors do not extend beyond the contract period. 

Concur Target Completion Date: Completed 

Action Plan: The Credentialing and Privileging Coordinator has a listing 

of all sharing agreements and associated expiration dates. Effective 

immediately, as contract physicians’ privileges become due for renewal, 

their privileges will be granted to not extend beyond the contract period. 

Recommendation 2. We recommended that the Acting VISN Director 

ensure that the Medical Center Director requires that C&P documentation 

is maintained in accordance with VHA policy. 

Concur Target Completion Date: Completed 

Action Plan: Chief of Staff acknowledges that the Medical Staff’s 

Executive Committee minutes did not reflect the documents reviewed and 

rationale for the stated conclusions for a 12-month period prior to the OIG 

CAP visit. Since April of 2009, the privileging decisions of the Provider 

Staff Evaluation and Credentialing Subcommittee have been appropriately 

documented, and the minutes reflect that documents were reviewed and 

reflect the rationale for the stated conclusions. 

Recommendation 3. We recommended that the Acting VISN Director 

ensure that the Medical Center Director requires that supervisors provide 

written notification of completed PR actions to the PRC and that 

committee minutes reflect actions taken. 

Concur Target Completion Date: Completed 

Action Plan: The Risk Manager has developed a form, “Service Chief 

Meeting with Involved Practitioner Form,” which is initiated by the Risk 

Manager after the Peer Review Advisory Group (PRAG) has given a final 

level of 2 or 3 to any case presented at the committee meeting. The form 

is delivered to the service chief for completion. Completion of this form 

constitutes the service chief speaking with the involved provider, providing 

VA Office of Inspector General 19 
 

 

 

Combined Assessment Program Review of the Iowa City VA Medical Center, Iowa City, Iowa 

education/counseling about the issue involved, and documenting any 

other follow up. The form is then returned to the Risk Manager where it is 

noted in the next PRAG meeting minutes as a written follow up for a PR 

recommendation. The form is permanently filed in the PR case folder. 

Recommendation 4. We recommended that the Acting VISN Director 

ensure that the Medical Center Director requires that clinical disclosure of 

adverse events is conducted and documented in accordance with VHA 

policy. 

Concur Target Completion Date: October 1, 2009 

Action Plan: A CPRS template is in the process of being developed for 

clinical disclosure of adverse events. All clinical disclosures will be 

documented using this template in the future. The VA Medical Center has 

been using a CPRS template for formal disclosures of adverse events. 

Both the formal and clinical disclosures will be tracked by Patient Safety 

and Quality Improvement. 

Recommendation 5. We recommended that the Acting VISN Director 

ensure that the Medical Center Director requires that identified safety 

deficiencies are corrected. 

Concur Target Completion Date: October 30, 2009 

Action Plan: A section has been added to the JC Readiness Rounds for 

security of medications, sharps, respiratory supplies, and cleaning 

products. Secured supplies carts have been order for the ICU unit. 

Managers are currently reviewing all clinical areas to ensure compliance. 

Recommendation 6. We recommended that the Acting VISN Director 

ensure that the Medical Center Director requires that identified patient 

privacy deficiencies are corrected. 

Concur Target Completion Date: Completed 

Action Plan: The Privacy Officer and Information Security Officer 

conduct weekly environment of care rounds to check for privacy and 

information security violations, which include unlocked computers, patient 

health information lying out in the open, identification badges, and physical 

privacy around the facility and community based outpatient clinics 

(CBOCs). The Privacy Officer and Information Security Officer have 

increased awareness throughout the facility by involving other staff to 

complete checks on environment of care rounds or when walking 

throughout the facility and educating staff on privacy and information 

security policies. When a privacy incident occurs, the Privacy Officer 

discusses the incident with the individual immediately and/or notifies the 

supervisor for corrective action/education. All VA employees, volunteers, 

VA Office of Inspector General 20 
 

 

 

 

 

Combined Assessment Program Review of the Iowa City VA Medical Center, Iowa City, Iowa 

and contractors are required to complete privacy and information security 

training annually and comply with the medical center’s privacy and 

information security policies. 

Recommendation 7. We recommended that the Acting VISN Director 

ensure that the Medical Center Director requires that locked MH unit staff 

and MSIT members receive environmental hazards training, as required 

by VHA. 

Concur Target Completion Date: October 1, 2009 

Action Plan: All locked Mental Health Unit staff and MSIT members will 

have completed EOC/MSIT training by August 24, 2009. The training will 

be reflected on the annual competency assessments, coupled with 

documentation from the staff in-services. 

Recommendation 8. We recommended that the Acting VISN Director 

ensure that the Medical Center Director requires that patient discharge 

summaries include active outpatient medications. 

Concur Target Completion Date: October 30, 2009 

Action Plan: Chief of Staff has requested that the Surgical Specialty 

Service Line ensure that all active outpatient medications are included in 

surgery discharge summaries no later than October 1, 2009. Monthly 

medical records audits will be completed by the Surgery Service Line. 

Recommendation 9. We recommended that the Acting VISN Director 

ensure that the Medical Center Director requires the proper disposition of 

medications brought into the medical center by MH patients. 

Concur Target Completion Date: Completed 

Action Plan: All patient medications brought into the medical center are 

being sent home with family members or mailed to the patient’s home, 

according to policy. Homeless patient medications are stored in the 

Outpatient Pharmacy until the patient is discharged from the hospital. 

Staff has been provided a copy of the policy, and daily checks are 

performed by the nursing administrator to ensure that no patient 

medications are kept on the unit. 

Recommendation 10. We recommended that the Acting VISN Director 

ensure that the Medical Center Director requires compliance with VHA 

regulations regarding documentation of SPC and MH provider 

collaboration for patients deemed at high risk for suicide. 

Concur Target Completion Date: Completed 

VA Office of Inspector General 21 
 

 

 

 

Combined Assessment Program Review of the Iowa City VA Medical Center, Iowa City, Iowa 

Action Plan: Patients at high risk for suicide are identified by the 

treatment team, and a note is entered in CPRS by the SPC. Members of 

the treatment team have been added as additional signers of this progress 

note. Concurrence is noted by their electronic signature. An audit of 

patients flagged in the past 6 months shows 100% compliance with 

treatment team documentation. 

Recommendation 11. We recommended that the Acting VISN Director 

ensure that the Medical Center Director requires that ED staff complete all 

inter-facility transfer documentation in accordance with VHA policy. 

Concur Target Completion Date: October 30, 2009 

Action Plan: A multidisciplinary workgroup has reviewed VHA policy and 

is completing an electronic progress note template that will meet VHA 

policy requirements. ED staff will complete all inter-facility transfer 

documentation in accordance with VHA policy no later than October 1, 

2009. Monthly audits will be completed by CPRS. 

Recommendation 12. We recommended that the Acting VISN Director 

ensure that the Medical Center Director defines processes to ensure 

effective hand-off communications when ED patients are admitted to 

inpatient units in the medical center. 

Concur Target Completion Date: October 1, 2009 

Action Plan: A template was developed for patient transfer between units 

including ED. The template has been implemented. The Medical Center 

Memorandum (MCM) on Handoff will be updated to reflect changes to the 

process. 

Recommendation 13. We recommended that the Acting VISN Director 

ensure that the Medical Center Director requires that ED managers 

complete competency assessments in accordance with medical center 

policy. 

Concur Target Completion Date: Completed 

Action Plan: ED staff has been educated, and competencies have been 

completed in accordance with the annual review requirement. 

Recommendation 14. We recommended that the Acting VISN Director 

ensure that the Medical Center Director requires that CNH patients 

receive follow-up visits and monitoring in accordance with VHA policy. 

Concur Target Completion Date: October 30, 2009 

VA Office of Inspector General 22 
Combined Assessment Program Review of the Iowa City VA Medical Center, Iowa City, Iowa 

Action Plan: The Community Health Nurse assigned to do follow-up 

visits and monitoring is assigned to the program on a 0.5 FTE basis, not 

as a collateral duty as was stated by the CNH Social Worker. This was 

not reflected in the Extended Care and Rehabilitation organizational chart 

at the time of the CAP review. The organizational chart has been 

changed to reflect the 0.5 assignment to CNH review. The Community 

Health Nurse will be instructed to complete her review notes in a more 

accurate and timely manner, and she will be provided with additional 

training in this process. In addition, her duties as a Community Health 

Nurse Coordinator have been further reduced in order to accommodate 

time for her to complete her nursing home visits and notes. Compliance 

with completion of nursing home notes will be monitored monthly as part 

of medical record review. 

VA Office of Inspector General 23 
Combined Assessment Program Review of the Iowa City VA Medical Center, Iowa City, Iowa 

Appendix C 

OIG Contact and Staff Acknowledgments 

Contact Paula Chapman, CTRS, Associate Director 

Chicago Office of Healthcare Inspections 

(708) 202-2672 

Contributors Lisa Barnes, MSW, Team Leader 

Judy Brown 

Shirley Carlile 

Stephanie Hills, RN 

Jennifer Reed, RN 

Roberta Thompson, MSW 

Ann Ver Linden, RN 

Jim Werner, Office of Investigations 

VA Office of Inspector General 24 
Combined Assessment Program Review of the Iowa City VA Medical Center, Iowa City, Iowa 

Appendix D 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VA Midwest Health Care Network (10N23) 

Director, Iowa City VA Medical Center (636A8/00) 

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: Roland W. Burris, Richard J. Durbin, Chuck Grassley, Tom Harkin 

U.S. House of Representatives: Bruce L. Braley, Phil Hare, Tom Latham, 

David Loebsack 

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

VA Office of Inspector General 25