Department of Veterans Affairs

Office of Inspector General

Office of Healthcare Inspections

Report No. 08-03043-70

Combined Assessment Program 

Review of the 

West Texas VA Health Care System 

Big Spring, Texas 

February 19, 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 West Texas VA Health Care System, Big Spring, Texas 

Table of Contents 

Page 

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

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

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

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

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

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

Quality Management ......................................................................................... 3

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

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

Pharmacy Operations and Controlled Substances Inspections......................... 8

Emergency/Urgent Care Operations ................................................................. 9

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

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

Staffing .............................................................................................................. 11

Survey of Healthcare Experiences of Patients .................................................. 11

Appendixes

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

B. System Director Comments............................................................................... 15

C. OIG Contact and Staff Acknowledgments ......................................................... 19

D. Report Distribution............................................................................................. 20

VA Office of Inspector General 
Combined Assessment Program Review of the West Texas VA Health Care System, Big Spring, Texas 

Executive Summary 

Introduction During the week of December 1–5, 2008, the OIG conducted 

a Combined Assessment Program (CAP) review of the West 

Texas VA Health Care System (the system), Big Spring, TX. 

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 

117 system employees. The system is part of Veterans 

Integrated Service Network (VISN) 18. 

Results of the 

Review 

The CAP review covered eight operational activities. We 

made recommendations in five of the activities reviewed. 

For these activities, the system needed to: 

• Complete root cause analyses (RCAs) within the 45-day 

timeframe. 

• Review medical records at the point of care on an ongoing 

basis. 

• Monitor the copy and paste function in the electronic 

medical record. 

• Ensure that clinicians document pain medication 

effectiveness in a timely manner. 

• Correct identified environment of care (EOC) deficiencies. 

• Ensure that monthly controlled substances (CS) 

inspections are completed the day initiated, as required by 

Veterans Health Administration (VHA) policy. 

• Ensure that registered nurses (RN) who work in the urgent 

care center (UCC) achieve the required clinical 

competencies annually. 

The system complied with selected standards in the following 

three activities: 

• Coordination of Care. 

• Staffing. 

• Survey of Healthcare Experiences of Patients (SHEP). 

This report was prepared under the direction of 

Linda G. DeLong, Director, Dallas Office of Healthcare 

Inspections. 

VA Office of Inspector General i
Combined Assessment Program Review of the West Texas VA Health Care System, Big Spring, Texas 

VA Office of Inspector General ii

Comments The VISN and System Directors agreed with the CAP review 

findings and recommendations and provided acceptable 

improvement plans. (See Appendixes A and B, 

pages 14–18, 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 West Texas VA Health Care System, Big Spring, Texas 

VA Office of Inspector General 1 

Introduction 

Profile Organization. The system is a Veterans Rural Access 

Hospital located in Big Spring, TX, that provides a limited 

range of inpatient and outpatient health care services. 

Outpatient care is also provided at six community based 

outpatient clinics in Abilene, Fort Stockton, Odessa, 

Stamford, and San Angelo, TX, and in Hobbs, NM. The 

system is part of VISN 18 and serves a veteran population of 

more than 59,000 in 32 counties in Texas and 1 county in 

New Mexico. 

Programs. The system provides outpatient services in the 

areas of medicine, rehabilitation, and dentistry and inpatient 

services in the areas of medicine, domiciliary care, and 

extended care. It also provides fee based community 

services and referrals to other VISN 18 facilities. The 

system has 25 hospital beds and 40 community living center 

(CLC)1 beds. The domiciliary is currently a temporary 

12-bed unit until the permanent 40-bed unit is constructed. 

Affiliations and Research. The system is affiliated with 

Texas Tech University Health Sciences Center, the 

University of Houston, Angelo State University, New Mexico 

State University, and the University of Utah. It provides 

training for one medicine resident and two ophthalmology 

residents. Currently, the system does not have a research 

program. 

Resources. In fiscal year (FY) 2008, medical care 

expenditures totaled $83.4 million. The FY 2009 medical 

care budget is $87.8 million. FY 2008 staffing was 

503 full-time employee equivalents (FTE), including 

23 physician and 139 nursing FTE. 

Workload. In FY 2008, the system treated 17,545 unique 

patients and provided 1,979 inpatient days in the hospital 

and 10,068 days in the CLC. The inpatient care workload 

totaled 713 discharges, and the average daily census, 

including CLC patients, was 33. Outpatient workload totaled 

142,630 visits. 

 

1

 A CLC (formerly called a nursing home care unit) provides compassionate, person-centered care in a safe and 

homelike environment to eligible veterans who require a nursing home level of care. 
Combined Assessment Program Review of the West Texas VA Health Care System, Big Spring, Texas 

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 eight activities: 

• Coordination of Care.

• Emergency/Urgent Care Operations.

• EOC.

• Medication Management. 

• Pharmacy Operations and CS Inspections.

• QM.

• SHEP.

• Staffing.

The review covered system operations for FY 2008 and 

FY 2009 through December 1, 2008, and was done in 

accordance with OIG standard operating procedures for CAP 

reviews. Also, we followed up on select recommendations 

from our prior CAP review of the system (Combined 

Assessment Program Review of the West Texas VA Health 

Care System, Big Spring, Texas, Report No. 06-00661-175, 

VA Office of Inspector General 2 
Combined Assessment Program Review of the West Texas VA Health Care System, Big Spring, Texas 

July 24, 2006). The system had corrected all findings related 

to health care from our prior CAP review. 

We also followed up on recommendations from two reports 

by VHA’s Office of the Medical Inspector (OMI) (Final 

Report: Review of Complaints Regarding the Quality of 

Medical Care, West Texas VA Health Care System, Big 

Spring, Texas, February 26, 2003; Final Report: Review of 

the Surgical Service, West Texas VA Health Care System, 

Big Spring, Texas, August 14, 2003). In the first report, the 

OMI made recommendations to improve patient and staff 

safety, access to care, system leadership, and the quality of 

medical care. In the second report, the OMI made 

recommendations to improve or discontinue surgical 

services at the system. For both reports, we reviewed 

documentation of the system’s follow-up. We found the 

improvement actions to be acceptable, and we consider the 

OMI recommendations closed for both reports. 

During this review, we presented fraud and integrity 

awareness briefings for 117 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 reportable findings.

Results 

Review Activities With Recommendations 

Quality 

Management 

The purpose of this review was to evaluate whether the 

system had a comprehensive QM program designed to 

monitor patient care and whether senior managers actively 

supported the program’s activities. We evaluated policies, 

performance improvement (PI) data, and other relevant 

documents. We interviewed appropriate senior managers 

and the QM Coordinator. 

The system’s QM program was generally effective, and 

senior managers supported the program through 

participation in and evaluation of PI initiatives and through 

VA Office of Inspector General 3 
Combined Assessment Program Review of the West Texas VA Health Care System, Big Spring, Texas 

VA Office of Inspector General 4 

allocation of resources to the program. However, we 

identified the following areas that needed improvement. 

Patient Safety. In order to minimize inadvertent harm to 

patients consequent to their medical care and as part of 

VHA’s patient safety improvement initiatives, VHA policy2

requires that RCAs be completed. The system completed 

eight individual RCAs in the last 12 months; however, three 

of the eight did not meet the 45-day timeframe established 

by VHA. 

Medical Records Review. Health Information Management 

Service had not ensured that medical records were reviewed 

on an ongoing basis at the point of care by providers who 

document in the record. A representative sample of inpatient 

and outpatient records from each service must be reviewed 

to ensure that adequate, timely, complete, and properly 

authenticated documentation is being accomplished in 

accordance with Joint Commission (JC) standards and VHA 

policy.3

Also, the system’s local policy states when it is appropriate 

to copy information from one part of the medical record to a 

current progress note. However, the system did not monitor 

this function to identify violations. 

Recommendation 1 We recommended that the VISN Director ensure that the 

System Director requires that RCAs are completed within 

45 days, in accordance with VHA policy. 

The VISN and System Directors concurred with the finding 

and recommendation. The system implemented an action 

plan. All RCAs chartered since March 2008 have been 

completed within 45 days. The corrective action is 

acceptable, and we consider this recommendation closed. 

Recommendation 2 We recommended that the VISN Director ensure that the 

System Director requires that medical records are reviewed 

on an ongoing basis at the point of care by providers who 

document in the record, in accordance with VHA policy. 

The VISN and System Directors concurred with the finding 

and recommendation. The Chief of Health Information 

Management Service will identify encounters for each 

 

2

 VHA Handbook 1050.01, VHA National Patient Safety Improvement Handbook, May 23, 2008. 3 VHA Handbook 1907.01, Health Information Management and Health Records, August 25, 2006.
Combined Assessment Program Review of the West Texas VA Health Care System, Big Spring, Texas 

VA Office of Inspector General 5 

physician to review. The results of these monthly reviews 

will be reported on a quarterly basis to the Clinical Executive 

Board (CEB). QM will conduct monthly inpatient reviews. 

The results of inpatient reviews will be reported monthly to 

the Medical Records Review Committee and quarterly to the 

CEB. The improvement plans are acceptable, and we will 

follow up on the completion of the planned actions. 

Recommendation 3 We recommended that the VISN Director ensure that the 

System Director requires that the copy and paste function in 

the electronic medical record is monitored to identify 

violations, in accordance with local policy. 

The VISN and System Directors concurred with the finding 

and recommendation. Coders will review progress notes 

monthly to ensure that copy and paste activities are 

conducted in accordance with local policy. The corrective 

action is acceptable, and we consider this recommendation 

closed. 

Medication 

Management 

The purpose of this review was to evaluate whether VHA 

facilities had adequate medication management practices. A 

safe medication management system includes medication 

ordering, administering, and monitoring. 

We reviewed selected medication management processes 

on the medicine unit and the CLC. We found appropriate 

use of patient armbands to correctly identify patients prior to 

medication administration, and we determined that 

self-medication administrations were completed safely and 

accurately. However, we identified an issue that needed 

improvement. 

Pain Medication Effectiveness. VHA regulations4

 and local 

policy require that the effects of pain medications be 

monitored. Local policy defined an appropriate timeframe for 

documentation of pain medication effectiveness. We found 

that 44 (49 percent) of 89 administered doses of pain 

medications were documented for effectiveness. We noted 

that of those 44 doses, 23 (52 percent) met the timeframe 

outlined in local policy for documentation of patient 

response. Without appropriate documentation and follow-up, 

clinicians could not be assured that patients’ pain was 

effectively managed. 

 

4

 VHA Directive 2003-021, Pain Management, May 2, 2003. 
Combined Assessment Program Review of the West Texas VA Health Care System, Big Spring, Texas 

We recommended that the VISN Director ensure that the 

System Director requires clinicians to document pain 

medication effectiveness in a timely manner. 

Recommendation 4 

The VISN and System Directors concurred with the findings 

and recommendation. Charge nurses will utilize narcotic 

administration reports to verify that pain assessments are 

documented in a timely manner. Night shift charge nurses 

will conduct 24-hour reviews of all administered pain 

medications to ensure that pain assessments are 

documented in the Bar Code Medication Administration 

system. The improvement plans are acceptable, and we will 

follow up on the completion of the planned actions. 

Environment of 

Care 

The purpose of this review was to determine if the system 

maintained a safe and clean health care environment. The 

system is required to provide a comprehensive EOC 

program that fully meets VA National Center for Patient 

Safety, Occupational Safety and Health Administration, and 

JC standards. The infection control (IC) program was 

evaluated to determine compliance with VHA directives 

based on the management of data collected and processes 

in which the data was used to improve performance. 

We inspected the medicine unit, the CLC, and primary care 

and specialty clinics. The system was generally clean and 

effectively maintained. Managers and staff were responsive 

to environmental concerns identified during our inspection, 

and those concerns were resolved while we were onsite. 

The IC program monitored and reported data to clinicians for 

implementation of quality improvements. However, we 

identified the following conditions that needed improvement. 

Environmental Rounds. Environmental rounds conducted by 

the system’s inspection team allow each discipline 

participating to identify and correct discrepancies, unsafe 

working conditions, and other regulatory violations. 

Representation from each discipline enables the team to 

cover the system in depth. A Deputy Under Secretary for 

Health for Operations and Management memorandum 

issued on March 5, 2007, requires the Information Security 

Officer (ISO) to be included as a team member on EOC 

rounds. The ISO or the ISO’s designee participated in 

11 (24 percent) of 46 weeks of EOC rounds. 

VA Office of Inspector General 6 
Combined Assessment Program Review of the West Texas VA Health Care System, Big Spring, Texas 

VA Office of Inspector General 7 

Safety. To minimize the risk of patients wandering away 

from designated areas, VHA policy5

 outlines standards for 

monitoring and maintaining electronic systems, such as the 

WanderGuard®. A basic system check should occur every 

24 hours to assure proper functioning. Maintenance of the 

WanderGuard® system should be consistent with the 

manufacturer’s guidelines, and a complete check must be 

performed annually. The system implemented the 

WanderGuard® system about 6 months ago; however, local 

policy did not clearly designate responsibility for monitoring 

and maintaining the system on the CLC unit. The local 

policy was revised while we were onsite. 

Environment of Care Deficiency Monitors. EOC inspections 

identify concerns for appropriate actions. VHA facilities are 

required to inspect administrative and clinical areas 

semi-annually to identify environmental deficiencies and 

initiate timely resolutions. VHA facilities are required to 

develop a tool to track and trend EOC inspections, 

deficiencies identified, and corrective actions taken. The 

target score for EOC performance measures (PMs) is 

85 percent or better. The system did not meet the target 

score for deficiencies corrected within 14 days. In addition, 

the system did not meet the target score for deficiencies that 

cannot be corrected within 14 days but have been addressed 

with a plan for action. However, the system had recognized 

the issue and had implemented corrective actions. 

Infection Control. Methods are required to reduce the risks 

of infection associated with cross-contamination, and there 

are systems in place to communicate with staff about their 

responsibilities in preventing the spread of infection. We 

found clean supplies and dirty linens in close proximity in the 

same rooms. This same issue was a finding in the 2006 and 

2007 Annual Workplace Evaluations. While we were onsite, 

managers moved the clean supplies to different rooms. 

Recommendation 5 We recommended that the VISN Director ensure that the 

System Director requires that identified EOC deficiencies are 

corrected. 

The VISN and System Directors concurred with the findings 

and recommendation. Follow-up EOC rounds have been 

rescheduled for 11 days after initial rounds to allow time for 

reported deficiencies to be corrected. The ISO will 

 

5

 VHA Directive 2008-057, Management of Wandering and Missing Patient Events, September 23, 2008. 
Combined Assessment Program Review of the West Texas VA Health Care System, Big Spring, Texas 

VA Office of Inspector General 8 

participate on follow-up rounds to eliminate scheduling 

conflicts with initial rounds. Service chiefs now receive 

weekly progress reports on the correction of EOC 

deficiencies, and the system met the PMs for 85 percent 

completion for the 4th quarter of FY 2008. The improvement 

plans are acceptable, and we will follow up on the 

completion of the planned actions. 

Pharmacy 

Operations and 

Controlled 

Substances 

Inspections 

The purpose of this review was to evaluate whether VA 

health care facilities had adequate controls to ensure the 

security and proper management of CS and the pharmacies’ 

internal physical environments. We also determined whether 

clinical managers had processes in place to monitor patients 

prescribed multiple medications to avoid polypharmacy, 

especially in vulnerable populations. 

We reviewed VHA regulations6

 governing pharmacy and CS 

security, and we assessed whether the system’s policies and 

practices were consistent with VHA requirements. We 

inspected inpatient and outpatient pharmacies for security, 

EOC, and IC concerns. Additionally, we reviewed policies 

and procedures and interviewed the CS Coordinator, 

pharmacy managers, and the Chief of Police Service. 

Pharmacological regimens involving multiple medications are 

often necessary to prevent and maintain disease states; 

however, excessive use of medications can result in adverse 

reactions and increased risks of complications. 

Polypharmacy is more complex than just the number of 

drugs that patients are prescribed. The clinical criteria to 

identify polypharmacy are the use of: (a) medications that 

have no apparent indication, (b) therapeutic equivalents to 

treat the same illness, (c) medications that interact with other 

prescribed drugs, (d) inappropriate medication dosages, and 

(e) medications to treat adverse drug reactions.7

 Some 

literature suggests that that elderly patients and mental 

health patients are among the most vulnerable populations 

for polypharmacy.8

 Our review showed that managers 

followed processes to ensure that medication regimens were 

 

6

 VHA Handbook 1108.1, Controlled Substances (Pharmacy Stock), October 4, 2004; VHA Handbook 1108.2, 

Inspection of Controlled Substances, August 29, 2003; VHA Handbook 1108.5, Outpatient Pharmacy, 

May 30, 2006; VHA Handbook 1108.6, Inpatient Pharmacy, June 27, 2006. 7

 Yvette C. Terrie, BSPharm, RPh, “Understanding and Managing Polypharmacy in the Elderly, Pharmacy Times,

December 2004. 

8

 Terrie, Pharmacy Times, December 2004; Vijayalakshmy Patrick, M.D., et al., “Best Practices: An Initiative to 

Curtail the Use of Antipsychotic Polypharmacy in a State Psychiatric Hospital,” Psychiatric Services, 57:21–23, 

January 2006. 
Combined Assessment Program Review of the West Texas VA Health Care System, Big Spring, Texas 

VA Office of Inspector General 9 

reviewed for patients who were prescribed multiple 

medications to avoid polypharmacy. 

CS inspections were conducted monthly, in accordance with 

VHA regulations. Training records showed that the CS 

Coordinator and inspectors received appropriate training to 

execute their duties. We also found that managers reported 

all CS diversions or suspected diversions to the OIG. The 

pharmacies’ internal environments were clean and well 

maintained. However, our reviewed showed that managers 

needed to improve in the following area. 

Monthly Controlled Substances Inspections. We reviewed 

documentation for six monthly CS inspections completed 

May–October 2008. In two of the months reviewed, the CS 

inspections were not completed on the same day initiated, as 

required by VHA policy.9

Recommendation 6 We recommended that the VISN Director ensure that the 

System Director requires that monthly CS inspections are 

completed the day initiated, as required by VHA policy. 

The VISN and System Directors concurred with the finding 

and recommendation. The CS Coordinator will adhere to the 

requirement that CS inspectors complete CS inspections the 

same day initiated and will instruct CS inspectors to check in 

by noon the day of inspection to avert any potential delays. 

The corrective action is acceptable, and we consider this 

recommendation closed. 

Emergency/Urgent 

Care Operations 

The purpose of this review was to evaluate selected aspects 

of patient care and operations in VHA emergency 

departments (EDs) and UCCs, such as clinical services, 

consults, transfers, discharges, staffing, and staff 

competencies. We also determined whether the physical 

environment was clean and safe and whether managers 

maintained equipment appropriately. The system did not 

have an ED but did have a UCC that was open 7 days a 

week, 24 hours a day. 

We interviewed the UCC nurse manager, transfer 

coordinators, and the system’s Director. We reviewed 

policies and other pertinent documents, including equipment 

maintenance records. We reviewed medical records of 

patients with consults to other VHA facilities within the VISN 

 

9

 VHA Handbook 1108.2.
Combined Assessment Program Review of the West Texas VA Health Care System, Big Spring, Texas 

VA Office of Inspector General 10 

and medical records of patients transferred to other medical 

facilities. Our review showed that consults, transfers, and 

staffing were appropriate. Our EOC rounds revealed a clean 

and safe environment, and we found that managers 

appropriately maintained equipment. We identified one area 

that needed improvement. 

Competencies. We reviewed the competency files and 

training summaries of three RNs who worked in the UCC, 

and we interviewed nurse managers. VHA policy10 and JC 

standards require that nursing staff assignments be 

congruent with patient care needs and employee 

qualifications. The system required that UCC RNs 

achieve certain competencies annually. These 

competencies were the performance of: (a) glucose testing, 

(b) electrocardiograms, and (c) breathalyzer11 tests. 

Interviews and our review of the files revealed that: 

• None of the three RNs had current competencies for 

breathalyzer tests. 

• Two of the RNs did not have copies of current nursing 

licensure in their competency files. 

Recommendation 7 We recommended that the VISN Director ensure that the 

System Director requires that RNs who work in the UCC 

achieve the required clinical competencies annually. 

The VISN and System Directors concurred with the findings 

and recommendation. The UCC nurse manager will 

implement a competency spreadsheet for initial employment 

and will use this spreadsheet to track required annual 

reviews. The spreadsheet will also be used to schedule 

annual clinical competency reviews before their due dates. 

The improvement plans are acceptable, and we will follow up 

on the completion of the planned actions. 

Review Activities Without Recommendations 

Coordination of 

Care 

The purpose of this review was to evaluate whether VHA 

facilities had adequate processes to ensure coordination of 

care across the continuum of patient services. We reviewed 

three aspects of care: (a) patient consults, (b) patient 

intra-facility transfers, and (c) patient discharges. We found 

 

10 VHA Manual M-2, Part V; Clinical Affairs, Nursing Service; July 13, 1989. 11 The breathalyzer is a device that measures the alcohol content of an individual’s breath and estimates the amount 

of alcohol in the blood. 
Combined Assessment Program Review of the West Texas VA Health Care System, Big Spring, Texas 

that providers managed patient consults, intra-facility 

transfers, and discharges appropriately. We made no 

recommendations. 

Staffing The purpose of this review was to evaluate whether VHA 

facilities had developed comprehensive nurse staffing 

guidelines and whether the guidelines had been met. We 

reviewed nurse staffing documents for all inpatient units, and 

we interviewed nurse managers. We found the staffing 

methodology to be appropriate. We made no 

recommendations. 

Survey of 

Healthcare 

Experiences of 

Patients 

The purpose of this review was to assess the extent that 

VHA facilities use quarterly survey results of patients’ health 

care experiences with the VHA system 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 PM target results for 

patients reporting overall satisfaction of “very good” or 

“excellent” at 76 percent for inpatients and 77 percent for 

outpatients. Facilities are expected to address areas that fall 

below target scores. Figures 1 and 2 on the next page show 

the system’s SHEP PM results for inpatients and outpatients, 

respectively. 

VA Office of Inspector General 11 
Combined Assessment Program Review of the West Texas VA Health Care System, Big Spring, Texas 

VA Office of Inspector General 12 

60

65

70

75

80

85

90

95

100

Qtr 4 (FY 06) Qtr 1 (FY 07) Qtr 2 (FY 07) Qtr 3 (FY 07) Qtr 4 (FY 07) Qtr 1 (FY 08) Qtr 2 (FY 08) Q

Quarter Reported

Percent Reporting Overall Quality as Very Good or Excellent

tr 3 (FY 08)

Facility

VISN

National

WEST TEXAS VA HEALTH CARE SYSTEM 

INPATIENT OVERALL QUALITY

BY QUARTER

Meets 

Target

Figure 1:

60

65

70

75

80

85

90

95

100

Qtr 4 (FY 06) Qtr 1 (FY 07) Qtr 2 (FY 07) Qtr 3 (FY 07) Qtr 4 (FY 07) Qtr 1 (FY 08) Qtr 2 (FY 08)

Quarter Reported

Percent Reporting Overall Quality as Very Good or Excellent

 Qtr 3 (FY 08)

Facility

VISN

National

WEST TEXAS VA HEALTH CARE SYSTEM 

OUTPATIENT OVERALL QUALITY

BY QUARTER

Figure 2:

Meets 

Target
Combined Assessment Program Review of the West Texas VA Health Care System, Big Spring, Texas 

VA Office of Inspector General 13 

The system did not meet the established target for 3 of the 

last 8 quarters of available data for inpatient overall 

satisfaction and all of the last 8 quarters for outpatient overall 

satisfaction. However, managers had identified opportunities 

for improvement based on the SHEP scores and had 

developed action plans targeting specific services and 

departments. Staff provided documentation for the 

implementation of action plans, ongoing activities, and action 

plan effectiveness for areas that fell below the target scores. 

Therefore, we made no recommendations. 
Combined Assessment Program Review of the West Texas VA Health Care System, Big Spring, Texas 

Appendix A 

VISN Director Comments 

VA Office of Inspector General 14 

Department of 

Veterans Affairs Memorandum 

Date: January 9, 2009 

From: Director, VA Southwest Health Care Network (10N/18) 

Subject: Combined Assessment Program Review of the West 

Texas VA Health Care System, Big Spring, Texas 

To: Director Dallas Healthcare Inspections Division (54DA) 

Director, Management Review Service (10B5) 

I concur with the attached facility draft responses to the recommendations 

for improvement contained in the Combined Assessment Program review 

at the West Texas VA Health Care System. If you have any questions or 

concerns, please contact Joan Funckes, Executive Assistant to the 

Network Director, VISN 18, at 602-222-2699. 

(original signed by:) 

Susan P. Bowers 
Combined Assessment Program Review of the West Texas VA Health Care System, Big Spring, Texas 

Appendix B 

System Director Comments 

VA Office of Inspector General 15 

Department of 

Veterans Affairs Memorandum 

Date: January 5, 2009 

From: Director, West Texas VA Health Care System (519/00) 

Subject: Combined Assessment Program Review of the West 

Texas VA Health Care System, Big Spring, Texas 

To: Director, Dallas Healthcare Inspections Division (54DA) 

I take this opportunity to thank the Office of Inspector General Combined 

Assessment Program (CAP) Survey Team for a professional, 

comprehensive, impartial, and educational survey conducted 

December 1–5, 2008. I appreciate the opportunity to provide comments to 

the report of the OIG CAP review of the West Texas VA Health Care 

System (WTVAHCS). I concur with the findings and the recommendations 

for improvement. The WTVAHCS staff have already begun corrective 

actions on all recommendations. 

The WTVAHCS staff are pleased with the results and improvements that 

resulted from the survey findings. The collaborative efforts of the experts 

on the CAP review team have contributed to improvements in the level of 

care, safety, and services that WTVAHCS provides our veterans. 

DANIEL MARSH 

Director 
Combined Assessment Program Review of the West Texas VA Health Care System, Big Spring, Texas 

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 System Director requires that RCAs are completed within 45 days, 

in accordance with VHA policy. 

Concur. 

The VISN Director emphasized the commitment to complete RCAs within 

45 days and WTVAHCS implemented an action plan. All RCAs chartered 

since March 2008 were completed within 45 days. WTVAHCS received 

the Bronze RCA Cornerstone Recognition Award in FY2008 for 

completing four RCAs and four Aggregate RCAs within 45 days. 

Target Completion Date: Completed. 

Recommendation 2. We recommended that the VISN Director ensure 

that the System Director requires that medical records are reviewed on an 

ongoing basis at the point of care by providers who document in the 

record, in accordance with VHA policy. 

Concur. 

The Chief of Health Information Management System will identify 

encounters for each physician to review on a monthly basis for clinical 

pertinence, quality, and appropriateness of care. Physicians will conduct 

monthly reviews that will be reported on a quarterly basis to the Clinical 

Executive Board (CEB). Quality Management will conduct inpatient point 

of care reviews on ten records monthly using a record review checklist. 

Review results will be reported to the Medical Records Review Committee 

monthly and to CEB on a quarterly basis. 

Target Completion Date: January 2009. 

Recommendation 3. We recommended that the VISN Director ensure 

that the System Director requires that the copy and paste function in the 

electronic medical record is monitored to identify violations, in accordance 

with local policy. 

Concur. 

VA Office of Inspector General 16 
Combined Assessment Program Review of the West Texas VA Health Care System, Big Spring, Texas 

WTVAHCS coders will review 50 progress notes monthly to ensure that 

copy and paste activities are conducted in accordance to criteria 

established in MCM 11-71 Copying, Pasting and Template Use. Results 

of the reviews will be submitted to Medical Record Review Committee and 

Medical Staff Committee on a monthly basis. 

Target Completion Date: Completed. 

Recommendation 4. We recommended that the VISN Director ensure 

that the System Director requires clinicians to document pain medication 

effectiveness in a timely manner. 

Concur. 

Local policy was in place with appropriate requirements, but it was not 

being followed. Registered Nurses (RNs) and Licensed Vocational 

Nurses (LVNs) have completed re-education on the policy and will comply. 

Charge Nurses will utilize narcotic administration reports to verify pain 

assessments are documented in a timely manner. The night shift Charge 

Nurses will conduct a 24-hour review of all administered pain medications 

to ensure pain assessments are documented in the Bar Code Medication 

Administration system. Monthly reports will be reviewed at unit staff 

meetings; quarterly reports will be reviewed by the Nurse Executive Board 

and forwarded to the Nurse-Pharmacy liaison qu00arterly. 

Target Completion Date: January 2009. 

Recommendation 5. We recommended that the VISN Director ensure 

that the System Director requires identified EOC deficiencies are 

corrected. 

Concur. 

Follow-up rounds were rescheduled to be conducted 11 days after initial 

rounds to allow time for reported deficiencies to be corrected. The Chief 

of Environmental Services reports 100% of outstanding deficiencies to the 

Administrative Executive Board through the Environment of Care 

Committee. Weekly progress reports on correction of EOC deficiencies 

are provided to Service Chiefs. Performance monitor for 85% completion 

rate was met fourth quarter of FY08. The Information Security Officer will 

participate on follow-up EOC rounds on Mondays to eliminate schedule 

conflicts with initial rounds on Thursdays. 

Target Completion Date: Completed. 

Recommendation 6. We recommended that the VISN Director ensure 

that the System Director requires that monthly CS inspections are 

completed the day initiated, as required by VHA policy. 

VA Office of Inspector General 17 
Combined Assessment Program Review of the West Texas VA Health Care System, Big Spring, Texas 

VA Office of Inspector General 18 

Concur. 

The Controlled Substance (CS) Coordinator will follow the VHA policy 

requirement for CS inspectors to complete CS inspections the same day 

and instruct CS inspectors to check in no later than noon the day of 

inspection to avert any potential delays. The CS Inspectors advise the CS 

Coordinator no later than noon on the day of inspection about progress 

and/or potential for delays. Results: All CS inspections since August 2008 

have been conducted and completed on the same day. 

Target Completion Date: Completed. 

Recommendation 7. We recommended that the VISN Director ensure 

that the System Director requires that RNs who work in the UCC achieve 

the required clinical competencies annually. 

Concur. 

The Urgent Care Center (UCC) Nurse Manager (NM) will implement a 

competency spreadsheet for initial employment and to track required 

annual reviews that will include Alcohol Strip Testing. The UCC NM will 

complete an annual review of competency requirements with 100% of 

registered nurses who work in UCC. On a quarterly basis, the 

spreadsheet will be used to schedule clinical competency reviews before 

their annual due date expires. 

Implementation Date: January 15, 2009. 
Combined Assessment Program Review of the West Texas VA Health Care System, Big Spring, Texas 

Appendix C 

VA Office of Inspector General 19 

OIG Contact and Staff Acknowledgments 

Contact Linda G. DeLong, Director 

Dallas Office of Healthcare Inspections 

(214) 253-3331 

Contributors Shirley Carlile 

Wilma Reyes 

Christy Bonilla, Office of Investigations 

Rachel Lewis, Office of Investigations 
Combined Assessment Program Review of the West Texas VA Health Care System, Big Spring, Texas 

Appendix D 

VA Office of Inspector General 20 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VA Southwest Health Care Network (10N18) 

Director, West Texas VA Health Care System (519/00) 

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: Kay Bailey-Hutchison, Jeff Bingaman, John Cornyn, Tom Udall 

U.S. House of Representatives: Henry Cuellar, Lloyd Doggett, Charlie A. Gonzalez, 

Rubẻn Hinojosa, Randy Neugebauer, Ciro Rodriguez, Lamar Smith, Harry Teague 

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