Department of Veterans Affairs

Office of Inspector General

Office of Healthcare Inspections

Report No. 08-03078-44

Combined Assessment Program 

Review of the 

W.G. (Bill) Hefner VA Medical Center 

Salisbury, North Carolina 

December 9, 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 W.G. (Bill) Hefner VA Medical Center, Salisbury, NC 

Table of Contents 

Page 

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

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

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

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

Organizational Strengths ........................................................................................... 3

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

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

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

Magnetic Resonance Imaging Safety ................................................................ 7

Physician Credentialing and Privileging ............................................................. 9

Review Activities Without Recommendations ......................................................... 10

Coordination of Care ......................................................................................... 10

Medication Management ................................................................................... 11

Quality Management ......................................................................................... 11

VHA Satisfaction Surveys ....................................................................................... 12

Appendixes

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

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

C. OIG Contact and Staff Acknowledgments ......................................................... 21

D. Report Distribution ............................................................................................. 22

VA Office of Inspector General 
Combined Assessment Program Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC 

Executive Summary 

Introduction During the week of September 21–25, 2009, the OIG 

conducted a Combined Assessment Program (CAP) review 

of the W.G. (Bill) Hefner VA Medical Center (the medical 

center), Salisbury, NC. 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 408 medical center employees. The medical 

center is part of Veterans Integrated Service Network 

(VISN) 6. 

Results of the 

Review 

The CAP review covered six operational activities. We 

identified the following organizational strengths and reported 

accomplishments: 

• Improved Care for Patients with Diabetes Mellitus (DM). 

• Improved Access to Care. 

We made recommendations in three of the activities 

reviewed. For these activities, the medical center needed to: 

• Ensure that all fire extinguishers are readily accessible. 

• Require that fire drills are conducted quarterly in the 

clinical laboratory. 

• Ensure that furnishings on the acute mental health (MH) 

unit meet safety standards. 

• Require that MH staff and the Multidisciplinary Safety 

Inspection Team (MSIT) members complete required 

annual training and that an effective tracking system is 

implemented to monitor compliance. 

• Ensure that hand hygiene data are monitored and reported 

and that deficiencies are addressed. 

• Ensure that designated employees receive N95 respirator 

fit testing and that an effective tracking system is 

implemented to monitor compliance. 

• Require that security of the mobile magnetic resonance 

imaging (MRI) unit is strengthened. 

• Ensure that MRI personnel training records contain 

documentation of annual MRI safety training. 

VA Office of Inspector General i
Combined Assessment Program Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC 

VA Office of Inspector General ii

• Ensure that MRI staff competency evaluations are 

completed in accordance with local policy. 

• Require that the MRI patient screening process is 

completed, as required by local policy. 

• Ensure that the Ongoing Professional Practice Evaluation 

(OPPE) plan, provider profiles, and privileges comply with 

Veterans Health Administration (VHA) requirements. 

The medical center complied with selected standards in the 

following three activities: 

• Coordination of Care. 

• Medication Management. 

• QM. 

This report was prepared under the direction of 

Carol Torczon, Associate Director, St. Petersburg Office of 

Healthcare Inspections. 

Comments The VISN and Medical Center Directors agreed with the CAP 

review findings and recommendations and provided 

acceptable improvement plans. (See Appendixes A and B, 

pages 14–20, for the full text of the Directors’ comments.) 

We will follow up on the planned actions until they are 

completed. 

 (original signed by:)

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

Assistant Inspector General for 

Healthcare Inspections 
Combined Assessment Program Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC 

Introduction 

Profile Organization. The medical center is located in Salisbury, 

NC, and provides a broad range of inpatient and outpatient 

health care services. Outpatient care is also provided at 

three outpatient clinics in Charlotte, Hickory, and 

Winston-Salem, NC. The medical center is part of 

VISN 6 and serves a veteran population of about 229,600 in 

23 counties throughout North Carolina. 

Programs. The medical center has 92 hospital beds and 

provides inpatient medical and surgical, MH, and advanced 

rehabilitation care services. The medical center also has 

150 community living center (CLC) beds and operates 

several regional referral and treatment programs, including 

the Specialized Intensive Post Traumatic Stress Disorder 

Unit and the Substance Abuse Residential Rehabilitation 

Treatment Program. 

Affiliations and Research. The medical center is affiliated 

with Wake Forest University’s School of Medicine and the 

Edward Via Virginia College of Osteopathic Medicine and 

provides training for 41 residents and 31 medical students. 

In addition, the medical center has 71 affiliated training 

programs in multiple health care fields. In fiscal year 

(FY) 2008, the medical center had 11 active research 

projects and a research budget of $295,000. Major areas of 

research included post-deployment MH of returning 

Operation Enduring Freedom and Operation Iraqi Freedom 

Veterans, traumatic brain injury, and rehabilitation of 

functional impairment associated with low vision and 

blindness. 

Resources. In FY 2008, medical care expenditures 

totaled more than $279.6 million. The FY 2009 medical care 

budget was over $307.5 million. FY 2008 staffing was 

1,785 full-time employee equivalents (FTE), including 

138 physician and 474 nursing FTE. 

Workload. In FY 2008, the medical center treated over 

67,000 unique patients. It provided more than 

26,700 inpatient days in the hospital and provided 

approximately 43,700 inpatient days in the CLC units. The 

inpatient care workload totaled 1,045 discharges, and the 

average daily census, including CLC patients, was 192. 

Outpatient workload totaled approximately 441,900 visits. 

VA Office of Inspector General 1 
Combined Assessment Program Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC 

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 six activities: 

• Coordination of Care.

• Environment of Care (EOC).

• Medication Management.

• MRI Safety.

• Physician Credentialing and Privileging (C&P).

• QM.

The review covered medical center operations for FY 2008 

and FY 2009 through September 21, 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 

W.G. (Bill) Hefner VA Medical Center, Salisbury, North 

Carolina, Report No. 06-02245-220, September 25, 2006). 

The medical center had corrected all findings related to 

health care from our prior CAP review. 

VA Office of Inspector General 2 
Combined Assessment Program Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC 

VA Office of Inspector General 3 

During this review, we also presented fraud and integrity 

awareness briefings to 408 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. Activities in the “Review Activities Without 

Recommendations” section have no findings requiring 

corrective action.

Organizational Strengths 

Improved Care for 

Patients With 

Diabetes Mellitus

The medical center implemented a systems-based approach 

to improve the delivery of care for patients with DM through 

standardization of care and goal-oriented outcomes. 

Patients with elevated HbA1c1 levels were targeted for 

improvement, and HEDIS2 standards were used to measure 

outcomes. Multiple approaches were utilized, including 

education, peer review, and peer comparison reports. The 

impact of these interventions was monitored weekly and 

monthly. Performance measures show that the overall care 

of patients with DM has improved. The medical center went 

from three of seven DM performance measures meeting or 

exceeding VHA’s target goals in FY 2008, to six of seven 

surpassing the target goals in FY 2009. 

Improved Access 

to Care 

In August 2008, the medical center implemented a VISN 

Support Services Center (VSSC) “Pending Report Process” 

to decrease the number of veterans waiting over 30 days for 

scheduled appointments. The process actively engages all 

levels of medical center staff, including schedulers, service 

administrative officers (AOs), associate chiefs of staff 

(ACOS), and senior management, in a systematic and 

proactive way of monitoring future scheduled appointments. 

Service AOs or ACOS report outstanding appointments on a 

weekly basis to medical center leadership. In FY 2009, there 

was an increase from 4 (40 percent) of 10 clinics to 

8 (80 percent) of 10 clinics meeting targets of fewer than 

30 days for new appointments. 

 

1

 HbA1c is a blood test that indicates how well a person’s blood sugar has been controlled over the last 2–3 months. 

2

 Healthcare Effectiveness Data and Information Set (HEDIS) is a group of measures related to quality of care that is 

reported by most health plans across the nation. It is owned by the National Committee for Quality Assurance. 
Combined Assessment Program Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC 

The VISN identified this process as a best practice, and a 

storyboard of the process was presented at the VHA 

Improvement Forum. 

Results 

Review Activities With Recommendations 

Environment of 

Care 

The purpose of this review was to determine whether the 

medical center maintained a safe and clean health care 

environment. VHA facilities are required to establish a 

comprehensive EOC program that fully meets VHA, National 

Center for Patient Safety, Occupational Safety and Health 

Administration, National Fire Protection Association (NFPA), 

and Joint Commission (JC) standards. 

We inspected the acute medical/surgical unit, four primary 

care clinics, the intensive care unit, the emergency 

department (ED), the dementia unit, two CLC units, and the 

acute and chronic MH units. We found that the medical 

center had an EOC program which included regularly 

scheduled rounds that identified environmental deficiencies. 

We determined that the infection control (IC) program 

monitored exposures and infections appropriately. In 

addition, the IC program monitored the outpatient influenza 

immunization rates and had a performance improvement (PI) 

plan in place to follow up as needed. 

During our inspection, we identified the following areas that 

needed improvement. 

Fire and Life Safety. The NFPA requires that fire 

extinguishers be readily accessible in the event of fire. We 

found fire extinguishers in locked closets in a primary care 

building, and only one person on each unit had a key to open 

the closet on their unit. 

In addition, the NFPA requires that the medical center 

conduct fire drills in clinical laboratories at least quarterly. 

We reviewed fire drill records for FY 2008 and FY 2009 

through September 9, 2009, and found that the laboratory 

only conducted one fire drill in each FY. 

MH Unit Safety. We found that dining room chairs in the 

acute MH unit were lightweight and did not meet JC 

standards for acute MH units. The standards require that 

dining room furnishings be physically heavy or secured to 

VA Office of Inspector General 4 
Combined Assessment Program Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC 

VA Office of Inspector General 5 

prevent them from being thrown or used as weapons. 

Managers provided us with a copy of a work order to replace 

the chairs in patients’ rooms; however, the work order did not 

include the dining room chairs. 

Training. VHA policy3 requires employees on a locked 

inpatient MH unit and members of the MSIT to complete 

annual training on environmental hazards that represent a 

threat to suicidal patients. We reviewed the training records 

for 29 MH employees and MSIT members and found that 

none had completed the training. 

IC. VHA4 requires the implementation of a hospital-wide 

hand hygiene program. We reviewed the medical center’s 

hand hygiene program data for the past 12 months. We 

found that the data reflected negative trends on several 

inpatient units and in several outpatient clinical areas, but the 

information was not routinely analyzed or reported to the 

appropriate committees. Furthermore, the deficiencies were 

not consistently addressed. 

In addition, Centers for Disease Control and Prevention 

guidelines require that all health care personnel entering 

rooms of patients with confirmed, suspected, or probable 

H1N1 influenza should wear, at a minimum, a fit-tested 

disposable N955

 respirator. We reviewed a total of 

23 employee records from Medicine Service (the 

bronchoscopy area), Radiology Service, the medical unit, 

and the ED for evidence of fit testing during the past 

12 months. We found that 6 (26 percent) of the 

23 employees had not received the required annual N95 fit 

testing. 

Recommendation 1 We recommended that the VISN Director ensure that the 

Medical Center Director requires that all fire extinguishers 

are readily accessible, in accordance with NFPA 

requirements. 

The VISN and Medical Center Directors concurred with the 

finding and recommendation. Locks have been removed 

from all cabinets containing fire extinguishers except for 

those on the locked MH units. All staff on the locked MH 

 

3

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

Checklist,” memorandum, August 27, 2007. 

4

 VHA Directive 2005-002, Required Hand Hygiene Practices, January 13, 2005. 5

 A disposable particulate respirator that has the ability to filter out 95 percent of particles greater than 0.3 microns 

in diameter. 
Combined Assessment Program Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC 

units have a key to unlock the cabinets. The corrective 

actions are acceptable, and we consider this 

recommendation closed. 

Recommendation 2 We recommended that the VISN Director ensure that the 

Medical Center Director requires that fire drills are conducted 

quarterly in the clinical laboratory, as required by the NFPA. 

The VISN and Medical Center Directors concurred with the 

finding and recommendation. The 2010 fire drill schedule 

has been updated to include the clinical laboratory. The 

implementation plans are acceptable, and we will follow up 

on the planned actions until they are completed. 

Recommendation 3 We recommended that the VISN Director ensure that the 

Medical Center Director requires that the furnishings on the 

acute MH unit meet safety standards. 

The VISN and Medical Center Directors concurred with the 

finding and recommendation. Replacement furnishings that 

meet JC standards have been approved. An interim safety 

plan is in effect until the new furniture is in place. The 

implementation plans are acceptable, and we will follow up 

on the planned actions until they are completed. 

Recommendation 4 We recommended that the VISN Director ensure that the 

Medical Center Director requires that MH staff and MSIT 

members complete the required annual training on 

environmental hazards that represent a threat to suicidal 

patients and that an effective tracking system is implemented 

to monitor compliance. 

The VISN and Medical Center Directors concurred with the 

finding and recommendation. MH staff and MSIT members 

have completed the required annual training on 

environmental hazards. A system is now in place to monitor 

initial and annual training compliance. The corrective actions 

are acceptable, and we consider this recommendation 

closed. 

Recommendation 5 We recommended that the VISN Director ensure that the 

Medical Center Director requires that hand hygiene data are 

monitored and reported and that deficiencies are addressed. 

The VISN and Medical Center Directors concurred with the 

findings and recommendation. A hospital-wide hand hygiene 

program has been implemented. Compliance data will be 

VA Office of Inspector General 6 
Combined Assessment Program Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC 

VA Office of Inspector General 7 

reported regularly to the appropriate committees, and action 

plans will be generated to address deficiencies. The 

implementation plans are acceptable, and we will follow up 

on the planned actions until they are completed. 

Recommendation 6 We recommended that the VISN Director ensure that the 

Medical Center Director requires that designated employees 

receive N95 respirator fit testing and that an effective 

tracking system is implemented to monitor compliance. 

The VISN and Medical Center Directors concurred with the 

finding and recommendation. A tracking system to monitor 

compliance has been developed, and currently, 100 percent 

of designated clinical staff have received N95 respirator fit 

testing. Safety staff will review compliance data regularly to 

enhance accountability. The implementation plans are 

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

they are completed. 

Magnetic 

Resonance 

Imaging Safety 

The purpose of this review was to evaluate whether the 

medical center maintained a safe environment and safe 

practices in the MRI areas. Safe MRI procedures minimize 

risk to patients, visitors, and staff and are essential to quality 

patient care. 

We inspected the permanent and mobile MRI areas, 

examined medical and training records, reviewed relevant 

policies, and interviewed key personnel. We determined that 

the medical center could strengthen some aspects of its MRI 

program. 

The medical center had conducted a risk assessment of the 

environment, as required by The JC. However, we found 

that the medical center was not in compliance in several 

areas even though compliance was indicated on the risk 

assessment. In addition, corrective actions were not tracked 

to completion. We identified the following areas that needed 

improvement. 

Environmental Safety. The medical center had appropriate 

signage and barriers to prevent unauthorized or accidental 

access to the permanent MRI area. However, security of the 

entrances to Zones III and IV6 in the mobile unit should be 

improved. The main door to the mobile unit remains 

unlocked when the MRI technician is in the unit. Also, when 

 

6

 Zones III and IV are areas restricted to only essential MRI personnel and previously screened patients. 
Combined Assessment Program Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC 

the technician is inside Zone IV with the patient, the door 

between Zones III and IV has to remain open due to the size 

of the space. Under these conditions, unauthorized or 

accidental access to Zone IV could occur. 

MRI Safety Training. Personnel who have access to the MRI 

area must receive annual MRI safety training. We reviewed 

the training records of six MRI personnel. Four had been in 

their MRI position for more than 2 years but had no 

documentation of training in 2008. All six received MRI 

safety training several weeks prior to our site visit to 

complete their 2009 training requirement. 

Competency Evaluations. MRI personnel had current 

competencies documented; however, neither the method of 

evaluating the competencies nor the level of competence 

achieved was documented, as required by local policy. 

Screening. Local policy requires that all patients must 

undergo safety screening prior to an MRI procedure. The 

process includes the use of a detailed checklist which 

requires documentation that the items have been reviewed 

with the patient at two separate times, including once just 

prior to entering the MRI suite. We reviewed the medical 

records of 10 patients who received an MRI. In all cases, we 

found a template screening form in each patient’s electronic 

medical record that was completed by the ordering physician 

at the time of the MRI request. However, there was no 

evidence that the patient was present when this form was 

completed. Although MRI technicians told us that they used 

this form and asked the patients the same questions when 

they arrived for their MRI, there was no documentation of 

this. In addition, the template form did not contain all 

required questions and did not include the patient’s 

signature. 

The template form allowed the ordering physician to indicate 

if the patient had any potential contraindications which might 

preclude the use of a contrast agent. Five (50 percent) of 

the 10 patients whose records we reviewed received a 

contrast agent. Although contraindications were indicated for 

three of these patients, we found no documentation to 

support the determination that the patients were not at risk. 

Recommendation 7 We recommended that the VISN Director ensure that the 

Medical Center Director requires that security of the mobile 

MRI unit is strengthened. 

VA Office of Inspector General 8 
Combined Assessment Program Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC 

VA Office of Inspector General 9 

The VISN and Medical Center Directors concurred with the 

findings and recommendation. A deadbolt lock is now in 

place to prevent unauthorized or accidental access to 

Zone IV in the mobile MRI Unit. The corrective actions are 

acceptable, and we consider this recommendation closed. 

Recommendation 8 We recommended that the VISN Director ensure that the 

Medical Center Director requires that MRI personnel training 

records contain documentation of annual MRI safety training. 

The VISN and Medical Center Directors concurred with the 

finding and recommendation. Annual safety training is now 

mandatory and is tracked through a VA computer program. 

The corrective actions are acceptable, and we consider this 

recommendation closed. 

Recommendation 9 We recommended that the VISN Director ensure that the 

Medical Center Director requires that MRI staff competency 

evaluations are completed in accordance with local policy. 

The VISN and Medical Center Directors concurred with the 

finding and recommendation. As of October 1, 2009, all MRI 

staff competencies were completed in accordance with local 

policy. The corrective actions are acceptable, and we 

consider this recommendation closed. 

Recommendation 10 We recommended that the VISN Director ensure that the 

Medical Center Director requires that the MRI patient 

screening process is completed, as required by local policy. 

The VISN and Medical Center Directors concurred with the 

findings and recommendation. The Computerized Patient 

Record System MRI screening template has been 

modified to reflect the requirements of local policy, and 

processes have been implemented to improve screening 

documentation. The corrective actions are acceptable, and 

we consider this recommendation closed. 

Physician 

Credentialing and 

Privileging 

The purpose of this review was to determine whether the 

medical center has consistent processes for C&P physicians. 

We reviewed selected VHA required elements7

 in physician 

C&P files and provider profiles. We also reviewed meeting 

minutes that included discussions relevant to our review. 

 

7

 VHA Handbook 1100.19, Credentialing and Privileging, November 14, 2008. 
Combined Assessment Program Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC 

We reviewed 10 physicians’ C&P files and profiles. We 

found that all 10 had current licenses and that primary 

source verification had been obtained for education, training, 

and certifications. Focused Professional Practice 

Evaluations were appropriately implemented for one 

physician requesting additional privileges and for two 

physicians hired within the past 12 months. Medical Staff 

Executive Committee and Professional Standards Board 

meeting minutes included detailed discussions regarding 

provider privileges. However, we identified the following 

area that needed improvement. 

OPPE. VHA regulations require thorough written plans with 

specific competency criteria for OPPE for all privileged 

physicians. We noted that seven of eight OPPE profiles 

reviewed lacked service-specific and provider-specific 

competency criteria and data to support current provider 

privileges. 

Recommendation 11 We recommended that the VISN Director ensure that the 

Medical Center Director requires that the OPPE plan, 

provider profiles, and privileges comply with VHA 

requirements. 

The VISN and Medical Center Directors concurred with the 

finding and recommendation. Service chiefs have been 

instructed to review and revise OPPE forms. All OPPEs will 

then be reviewed by the Professional Standards Board to 

ensure that the plans support the privileges requested and 

granted. In addition, changes will be made to standardize 

and consolidate data used in the evaluation process. The 

implementation plans are acceptable, and we will follow up 

on the planned actions until they are completed. 

Review Activities Without Recommendations 

Coordination of 

Care 

The purpose of this review was to evaluate whether inpatient 

intra-facility transfers, discharges, and post-discharge MH 

care were coordinated appropriately over the continuum of 

care and met VHA and JC requirements. Coordinated 

transfers, discharges, and post-discharge MH care are 

essential to an integrated, ongoing care process and optimal 

patient outcomes. 

We reviewed medical records for 17 intra-facility transfers 

and found that all of the records contained appropriate 

documentation. We found transfer notes from sending to 

VA Office of Inspector General 10 
Combined Assessment Program Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC 

receiving units. Also, nursing assessments were 

documented by the receiving units in a timely manner. 

We reviewed the medical records of 22 discharged patients 

and found that all patients received appropriate written 

discharge instructions. We also found documentation that 

the patients understood those instructions. 

Additionally, we reviewed the medical records of five patients 

recently discharged from the acute MH unit. We found 

documentation that patients received information about 

accessing emergency MH care and were given MH clinic 

appointments within 2 weeks of discharge. We also found 

documentation that MH providers either arranged for 

follow-up appointments or contacted the patients by phone 

within 7 days of discharge. We made no recommendations. 

Medication 

Management 

The purpose of this review was to evaluate whether VHA 

facilities had developed effective and safe medication 

management practices. We reviewed selected medication 

management processes on the acute medical/surgical unit, 

the acute MH unit, and the CLC units. 

We found that the medical center had a designated Bar 

Code Medication Administration Program coordinator who 

had appropriately identified and addressed problems. In 

general, nursing staff documented PRN (as needed) pain 

medication effectiveness within the timeframe specified by 

local policy, and pharmacy staff completed monthly 

medication reviews for CLC patients. We made no 

recommendations.

Quality 

Management 

The purposes of this review were to determine whether 

(a) the medical center had a comprehensive, effective QM 

program designed to monitor patient care activities and 

coordinate improvement efforts and (b) senior managers 

actively supported QM efforts and appropriately responded 

to QM results. We reviewed 14 QM and patient safety 

processes, and we evaluated policies, PI data, and other 

relevant documents. We interviewed appropriate senior 

managers, patient safety employees, and the QM 

Coordinator. 

The medical center’s QM program was effective and well 

managed, and senior managers supported the program 

through participation in and evaluation of PI initiatives and 

through allocation of resources to the program. Meaningful 

VA Office of Inspector General 11 
Combined Assessment Program Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC 

VA Office of Inspector General 12 

data were analyzed, trended, and utilized to improve patient 

care and patient safety. We made no recommendations. 

VHA Satisfaction Surveys 

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

facility performance. Patients are surveyed monthly, and data are summarized 

quarterly. Figure 1 below shows the medical center’s and VISN’s overall inpatient 

satisfaction scores for quarters 1 and 2 of FY 2009.8

 The target score is noted on the 

graph. 

Employees are surveyed annually. Figure 2 on the next page shows the medical 

center’s overall employee scores for 2007, 2008, and 2009. Since no target scores 

have been designated for employee satisfaction, VISN and national scores are included 

for comparison. 

 

8

 Due to technical difficulties with VHA’s outpatient survey data, no outpatient satisfaction scores are available for 

quarters 1 and 2 of FY 2009. 

40

45

50

55

60

65

70

75

80

85

90

Qtr 1 (FY 09) Qtr 2 (FY 09)

Percent Reporting Overall Quality as Very Good or 

Excellent

Quarter Reported

Facility

National

INPATIENT OVERALL QUALITY

BY QUARTER

Meets

Target

Figure 1:
Combined Assessment Program Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC 

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

5.0

2007 2008 2009

Facility

VISN

National

VA ALL EMPLOYEE SURVEY

OVERALL SATISFACTION Figure 2:

LEVEL OF SATISFACTION 

VA Office of Inspector General 13 
Combined Assessment Program Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC 

Appendix A 

VISN Director Comments 

VA Office of Inspector General 14 

Department of 

Veterans Affairs Memorandum 

Date: November 18, 2009 

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

Subject: Combined Assessment Program Review of the 

W.G. (Bill) Hefner VA Medical Center, Salisbury, North 

Carolina 

To: Associate Director, St. Petersburg Healthcare Inspections 

Division (54SP) 

Director, Management Review Service (10B5) 

I concur with all recommendations for improvement indentified in the 

report and approve the responses and action plans for each 

recommendation provided by the Director, Salisbury VA Medical Center. 

 (original signed by:) 

Daniel H. Hoffman, FACHE 

Network Director, VISN 6 
Combined Assessment Program Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC 

Appendix B 

Medical Center Director Comments 

VA Office of Inspector General 15 

Department of 

Veterans Affairs Memorandum 

Date: November 18, 2009 

From: Director, W.G. (Bill) Hefner VA Medical Center (659/00) 

Subject: Combined Assessment Program Review of the 

W.G. Hefner (Bill) VA Medical Center, Salisbury, North 

Carolina 

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

1. This is to acknowledge receipt and thorough review of the Office of 

Inspector General Combined Assessment Program Review draft 

report. I concur with all recommendations for improvement identified in 

the report. 

2. The responses and action plans for each recommendation are 

enclosed. 

3. Should you have any questions regarding the comments or 

implementation plans, please contact me at (704) 638-9000 ext. 3344. 

 (original signed by:) 

Carolyn Adams, Director 

W.G. (Bill) Hefner VA Medical Center 

 
Combined Assessment Program Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC 

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 VISN Director ensure 

that the Medical Center Director requires that all fire extinguishers are 

readily accessible, in accordance with NFPA requirements. 

Concur 

Facility Response: All Fire Extinguisher Equipment Cabinet locks have 

been removed except on the locked Mental Health units. All staff on the 

Mental Health units carry a key that unlocks the cabinet. 

Target Completion Date: Completed.

Recommendation 2. We recommended that the VISN Director ensure 

that the Medical Center Director requires that fire drills are conducted 

quarterly in the clinical laboratory, as required by the NFPA. 

Concur 

Facility Response: The 2010 Fire Drill Matrix has been updated to 

reflect this requirement. A fire drill was performed in the Laboratory on 

October 23, 2009. Fire drills are monitored through the Environment of 

Care Committee. 

Target Completion Date: Completed. 

Recommendation 3. We recommended that the VISN Director ensure 

that the Medical Center Director requires that the furnishings on the acute 

MH unit meet safety standards. 

Concur 

Facility Response: The Multidisciplinary Safety Inspection Team (MSIT) 

has identified a replacement for the dining room chairs, and the selection 

has been approved by leadership. The chairs have been ordered by 

Facility Management Service (FMS). The Interim Safety Plan to abate this 

risk is that patients are continuously monitored by staff while in the dining 

room. The dining room remains locked at all times other than meal times. 

This Mental Health Interim Safety Plan will remain in effect until the new 

chairs are in place. 

Target Completion Date: January 8, 2010. 

VA Office of Inspector General 16 
Combined Assessment Program Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC 

Recommendation 4. We recommended that the VISN Director ensure 

that the Medical Center Director requires that MH staff and MSIT 

members complete the required annual training on environmental hazards 

that represent a threat to suicidal patients and that an effective tracking 

system is implemented to monitor compliance. 

Concur 

Facility Response: The training module "Mental Health EOC Checklist 

Training" was created in My Peak on September 24, 2009. This is now a 

mandatory training for all Mental Health staff on the locked unit and the 

MSIT. The training is required annually. Compliance is tracked through 

the electronic TEMPO system (automatic documentation of My Peak 

training). The entire MSIT team and 100 percent of the required mental 

health staff have also completed the training. The Associate Chief of Staff 

for Mental Health and Behavioral Sciences has been assigned the 

responsibility for monitoring the annual training. 

Target Completion Date: Completed. 

Recommendation 5. We recommended that the VISN Director ensure 

that the Medical Center Director requires that hand hygiene data are 

monitored and reported and that deficiencies are addressed. 

Concur 

Facility Response: The Salisbury VAMC has implemented and enforced 

a hospital-wide hand-washing program in line with the CDC Universal 

Precaution recommendations and accepted principles of hand hygiene 

practice as indicated in the Salisbury VAMC IC Manual. Tracking and 

trending of hand hygiene compliance and aggregate data is reported 

monthly to the IC Committee, and quarterly to the Clinical Executive Board 

and the Executive Committee of the Governing Body. Action plans are 

generated for underperforming areas with appropriate reporting to 

respective committees. To address negative trends in hand hygiene, the 

accountability of staff has been enhanced by instituting progressive 

disciplinary action for recurrent violators while concurrently providing 

positive reinforcement to adherent staff. There is also a future plan for 

incentives to be given to staff that are compliant. Furthermore, to enhance 

compliance with hand hygiene, alcohol based hand sanitizers have been 

placed at all entrances to patient rooms, elevators and entrances. An 

increased number of carts with gowns, gloves, masks and alcohol based 

hand sanitizers have also been added on inpatient units. 

Target Completion Date: Completed. 

Recommendation 6. We recommended that the VISN Director ensure 

that the Medical Center Director requires that designated employees 

VA Office of Inspector General 17 
Combined Assessment Program Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC 

receive N95 respirator fit testing and that an effective tracking system is 

implemented to monitor compliance. 

Concur 

Facility Response: A list of required personnel has been identified, and 

currently, 100 percent have received N95 respirator fit testing. A process 

was immediately implemented to ensure all designated clinical staff who 

present at New Employee Orientation (NEO) will be fit tested by the third 

day of NEO by the Industrial Hygienist. Human Resources provides a 

listing of the incoming new employees to Safety staff the week prior to 

NEO training. The listing identifies the employees with their assigned 

service and job title, allowing the Industrial Hygienist to identify who needs 

to be enlisted in the program and receive the testing and training. A 

tracking system to monitor compliance has been developed. A report will 

be submitted monthly to the EOC Committee by the Industrial Hygienist 

and also quarterly to the Executive Committee of the Governing Body. 

Target Completion Date: Completed. 

Recommendation 7. We recommended that the VISN Director ensure 

that the Medical Center Director requires that security of the mobile MRI 

unit is strengthened. 

Concur 

Facility Response: A deadbolt lock is now being used when the 

technician is inside Zone IV with a patient to avoid unauthorized or 

accidental access to Zone IV. All staff are aware of this change. 

Target Completion Date: Completed. 

Recommendation 8. We recommended that the VISN Director ensure 

that the Medical Center Director requires that MRI personnel training 

records contain documentation of annual MRI safety training. 

Concur 

Facility Response: The MRI personnel annual safety training is now 

mandatory and has been placed on MY PEAK. Evidence of training can 

be tracked through TEMPO and noted on the updated competency 

checklists. 

Target Completion Date: Completed. 

Recommendation 9. We recommended that the VISN Director ensure 

that the Medical Center Director requires that MRI staff competency 

evaluations are completed in accordance with local policy. 

Concur 

VA Office of Inspector General 18 
Combined Assessment Program Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC 

Facility Response: As of October 1, 2009, all competencies have been 

completed utilizing the station format, which includes the method of 

evaluation and the level of competence. 

Target Completion Date: Completed. 

Recommendation 10. We recommended that the VISN Director ensure 

that the Medical Center Director requires that the MRI patient screening 

process is completed, as required by local policy. 

Concur 

Facility Response: The CPRS MRI screening template was modified to 

include the following statement: “Information above has been reviewed 

with the patient. The patient agrees to have MRI exam.” This statement 

guarantees that the clinician interacted with the patient to obtain current 

screening information. 

A new secondary screening questionnaire has been implemented. 

Additional questions required were included in the new questionnaire. 

Following completion by the patient, the technologist reviews the 

questionnaire with the patient to assure completion and understanding. At 

the end of this process, both the patient and the technologist sign the 

completed questionnaire and this document is scanned into the medical 

record. 

All patients are screened for potential contraindications to contrast agents. 

Those patients identified with potential contraindications who 

subsequently received contrast agents did not have documentation to 

support the use of the contrast agents. To correct this, a CPRS note is 

entered by the Imaging staff, acknowledging the review of the diagnosis, 

potential contraindications, and the Estimated Glomerular Filtration Rate, 

and the appropriateness of the use of contrast agents. 

Target Completion Date: Completed. 

Recommendation 11. We recommended that the VISN Director ensure 

that the Medical Center Director requires that the OPPE plan, provider 

profiles, and privileges comply with VHA requirements. 

Concur 

Facility Response: Immediately following the review, the C&P 

coordinator contacted the VA Hudson Valley Healthcare System, identified 

by the CAP reviewer as a “best practice,” to send samples of their OPPE 

forms. Upon receipt, these forms were forwarded to the service chiefs for 

their review and modification as appropriate to the service and providers’ 

specialty. The service chiefs were instructed to revise all OPPEs and 

send them to the Chief of Staff by Nov 30, 2009, for his review. The 

Professional Standards Board is scheduled to meet on 

VA Office of Inspector General 19 
Combined Assessment Program Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC 

VA Office of Inspector General 20 

December 10, 2009, to review all the OPPEs to ensure that the plan 

supports the privileges requested and granted. Furthermore, raw data for 

the service provider profile forms will be consolidated into one form to 

guarantee that all parameters in the OPPE are supported by relevant and 

measurable data. 

Target Completion Date: December 10, 2009. 
Combined Assessment Program Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC 

Appendix C 

VA Office of Inspector General 21 

OIG Contact and Staff Acknowledgments 

Contact Carol Torczon, Associate Director 

St. Petersburg Office of Healthcare Inspections 

(727) 395-2415 

Contributors David Griffith, Team Leader 

Darlene Conde-Nadeau 

Idell Louise Graham 

Deborah Howard 

Alice Morales-Rullan 

Katherine Owens 

Christa Sisterhen 

Bobby Kirby, Office of Investigations 
Combined Assessment Program Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, NC 

Appendix D 

VA Office of Inspector General 22 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

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

Director, W. G. (Bill) Hefner VA Medical Center (659/00) 

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: Richard Burr, Kay R. Hagan 

U.S. House of Representatives: Virginia Foxx, Larry Kissell, Patrick T. McHenry, 

Mel Watt 

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