Department of Veterans Affairs

Office of Inspector General

Office of Healthcare Inspections

Report No. 09-02921-57

Combined Assessment Program 

Review of the 

VA Roseburg Healthcare System 

Roseburg, Oregon 

January 5, 2010

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 VA Roseburg Healthcare System, Roseburg, Oregon 

Table of Contents 

Page 

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

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

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

Objective and Scope ............................................................................................... 1

Organizational Strength............................................................................................. 2

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

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

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

Medication Management ................................................................................... 4

Physician Credentialing and Privileging ............................................................. 6

Contracted/Agency Registered Nurses ............................................................. 6

Review Activities Without Recommendations ......................................................... 7

Coordination of Care ......................................................................................... 7

Environment of Care .......................................................................................... 8

Magnetic Resonance Imaging Safety ................................................................ 8

VHA Satisfaction Surveys ....................................................................................... 9

Appendixes

A. VISN Director Comments .................................................................................. 11

B. System Director Comments ............................................................................... 12

C. OIG Contact and Staff Acknowledgments ......................................................... 18

D. Report Distribution ............................................................................................. 19

VA Office of Inspector General 
Combined Assessment Program Review of the VA Roseburg Healthcare System, Roseburg, Oregon 

Executive Summary 

Introduction During the week of September 21–24, 2009, the OIG 

conducted a Combined Assessment Program (CAP) review 

of the VA Roseburg Healthcare System (the system), 

Roseburg, OR. The purpose of the review was to evaluate 

selected operations, focusing on patient care administration 

and quality management (QM). The system is part of 

Veterans Integrated Service Network (VISN) 20. 

Results of the 

Review 

The CAP review covered seven operational activities. We 

identified the following organizational strength and reported 

accomplishment: 

• Employee Influenza Program. 

We made recommendations in four of the activities reviewed. 

For these activities, the system needed to: 

• Require management to maintain comprehensive QM 

program documentation, monitoring, tracking, and timely 

reporting to oversight committees. 

• Require nurses to consistently document the effectiveness 

of as needed (PRN) pain medications in accordance with 

local policy. 

• Require pharmacists to consistently perform and document 

community living center (CLC) monthly medication 

reviews. 

• Ensure that the recently adopted Ongoing Professional 

Performance Evaluation (OPPE) and Focused 

Professional Practice Evaluation (FPPE) plans are fully 

implemented. 

• Validate that contracted/agency registered nurses (RNs) 

have completed mandatory training, have presented 

evidence of clinical competence, and have documentation 

of completed background investigations prior to providing 

patient care. 

The system complied with selected standards in the following 

three activities: 

• Coordination of Care. 

• Environment of Care (EOC). 

• Magnetic Resonance Imaging (MRI) Safety. 

VA Office of Inspector General i
Combined Assessment Program Review of the VA Roseburg Healthcare System, Roseburg, Oregon 

VA Office of Inspector General ii

This report was prepared under the direction of 

Virginia L. Solana, Director, Denver Office of Healthcare 

Inspections. 

Comments The VISN and System Directors agreed with the CAP review 

findings and recommendations and submitted acceptable 

improvement plans. (See Appendixes A and B, 

pages 11–17, for the full text of the Directors’ comments.) 

We will follow up on the planned actions until they are 

completed. 

 (original signed by Dana Moore, PhD, 

 Deputy Assistant Inspector General for

 Healthcare Insepctions for:)

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

Assistant Inspector General for 

Healthcare Inspections 
Combined Assessment Program Review of the VA Roseburg Healthcare System, Roseburg, Oregon 

Introduction 

Profile Organization. The system is a primary medical, mental 

health (MH), and surgical facility located in Roseburg, OR, 

that provides a broad range of inpatient and outpatient 

health care services. Outpatient care is also provided at 

three community based outpatient clinics in Brookings, 

Eugene, and North Bend, OR. Additionally, the system 

operates a Community Reintegration Services Center in 

Eugene, OR. The system is part of VISN 20 and serves a 

veteran population of about 62,000 throughout central and 

southern Oregon and northern California. 

Programs. The system provides medical, surgical, MH, 

protective care, transitional care, and reintegration services. 

It has 68 hospital beds and 55 CLC beds. 

Affiliations and Research. The system is affiliated with 

Umpqua and Mt. Hood Community Colleges, Graceland 

University, Gonzaga University, the University of Portland, 

and Oregon Health and Science University. The system 

provides a 4 to 8 week rotation for family practice residents 

in specialty procedures. It also provides training for 

undergraduate and graduate nursing, dietetic, health care 

administration, pharmacy, social work, emergency medical 

technology, optometry, and computer technology programs. 

Resources. In fiscal year (FY) 2009, medical care 

expenditures totaled $124 million. FY 2009 staffing was 

783 full-time employee equivalents (FTE), including 

40 physician and 269 nursing FTE. 

Workload. In FY 2009 through September 27, 2009, the 

system treated 24,823 unique patients and provided 

12,557 inpatient days in the hospital and 11,351 inpatient 

days in the CLC unit. The inpatient care workload totaled 

2,301 discharges, and the average daily census, including 

CLC patients, was 90. Outpatient workload totaled 

232,749 visits. 

Objective and 

Scope 

Objective. 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 objective of the CAP 

review is to conduct recurring evaluations of selected health 

care facility operations, focusing on patient care 

administration and QM.

VA Office of Inspector General 1 
Combined Assessment Program Review of the VA Roseburg Healthcare System, Roseburg, Oregon 

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: 

• Contracted/Agency RNs.

• Coordination of Care.

• EOC.

• Medication Management.

• MRI Safety.

• Physician Credentialing and Privileging (C&P).

• QM.

The review covered system operations for FY 2008 and 

FY 2009 through July 13, 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 system (Combined Assessment 

Program Review of the VA Roseburg Healthcare 

System, Roseburg, Oregon, Report No. 06-02817-42, 

December 13, 2006). The system had corrected all findings 

related to health care from our prior CAP review. 

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.

Organizational Strength 

Employee Influenza 

Program 

The Employee Influenza Program has significantly improved 

from 1999 to 2009. The flu vaccination rate has increased 

from 43 percent to 82 percent for employees and from 

38 percent to 82 percent for volunteers. The success of the 

program is due to increased education, direct contact with 

VA Office of Inspector General 2 
Combined Assessment Program Review of the VA Roseburg Healthcare System, Roseburg, Oregon 

staff, increased facility leadership and support, 

implementation of tracking and documentation, and 

improved vaccination accessibility. The system has 

exceeded the Veterans Health Administration’s (VHA’s) 

occupational health influenza vaccine performance measure. 

Results 

Review Activities With Recommendations 

Quality 

Management 

The purposes of this review were to evaluate whether (a) the 

system 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. To evaluate QM processes, we interviewed senior 

managers and reviewed the self-assessment completed by 

QM staff regarding compliance with QM requirements. 

The QM program was generally effective in providing 

oversight of the system’s quality of care. Also, it was evident 

that senior managers supported the program through 

participation in and evaluation of performance improvement 

(PI) initiatives. However, we identified the following area that 

needed improvement. 

Program Documentation, Monitoring, Tracking, and 

Reporting. Consistent documentation of PI activities, 

monitoring of outcomes, and tracking of goals were needed 

to improve the QM/PI programs reviewed. Also, quarterly 

reports to oversight committees needed to be submitted in a 

timely manner. 

Examples of program shortfalls included: 

• Current Basic Life Support training was not documented 

for 25 (5 percent) of 485 employees required to have life 

support training. 

• Monitoring of medication reconciliation for intra-facility 

transfers was not documented until the last quarter of 

FY 2009. 

• Moderate sedation adverse events, such as use of 

assisted ventilation, unplanned admissions, and 

untoward drug events, were not monitored, tracked, or 

reported. 

VA Office of Inspector General 3 
Combined Assessment Program Review of the VA Roseburg Healthcare System, Roseburg, Oregon 

VA Office of Inspector General 4 

• One of four quarterly Peer Review Committee reports 

was not submitted to the Executive Committee of the 

Medical Staff. 

• Three (23 percent) of 13 individual root cause analysis 

reviews completed in FY 2009 prior to June 2009 were 

not completed within 45 days, as required by VHA.1

• Two of four patient complaint reports were not submitted 

to a senior-level QM/PI committee. 

Recommendation 1 We recommended that the VISN Director ensure that the 

System Director requires comprehensive QM program 

documentation, monitoring, tracking, and timely reporting to 

designated oversight committees. 

The VISN and System Directors concurred with the findings 

and recommendation. The system implemented actions and 

standing agenda items to address program documentation, 

monitoring, tracking, and timely reporting to designated 

oversight committees. For example, the system revised the 

process for monitoring life support training and implemented 

mechanisms to monitor moderate sedation adverse events. 

The implementation plans are acceptable, and we will follow 

up on the planned actions until they are completed. 

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 inpatient medical/surgical, 

locked MH, intensive care, and CLC units. 

We reviewed the documentation provided and found that the 

designated Bar Code Medication Administration (BCMA) 

Program Coordinator had appropriately identified and 

addressed problems. We also reviewed a “PRN Reason 

Report” dated August 9–11, 2009. Medical records 

contained documentation that 19 doses of insulin had been 

given for elevated blood pressure instead of elevated blood 

sugar. Managers promptly corrected the problem by 

modifying BCMA reason codes while we were onsite. We 

determined this corrective action to be acceptable and made 

no recommendation for this finding. However, we identified 

the following two areas that needed improvement. 

Documentation of Pain Medication Effectiveness. Nurses 

did not consistently document the effectiveness of PRN pain 

 

1

 VHA Handbook 1050.01, VHA National Patient Safety Improvement Handbook, May 23, 2008. 
Combined Assessment Program Review of the VA Roseburg Healthcare System, Roseburg, Oregon 

medications in accordance with local policy requirements. 

We reviewed the BCMA records of 22 patients who were 

hospitalized in selected units at the time of our visit. For 

each patient, we reviewed documentation for several doses 

of pain medication. Nurses documented pain medication 

effectiveness within the locally required timeframe of 4 hours 

for only 39 (34 percent) of the 115 doses of pain medications 

reviewed. An action plan to address delays in documenting 

pain medication effectiveness was implemented in 

August 2009. 

CLC Monthly Medication Reviews. Accreditation standards 

require that a pharmacist review each CLC patient’s 

medication each month to identify any problems, such as 

interactions or duplications. Pharmacists did not consistently 

document monthly medication reviews for any of the 11 CLC 

patients whose records we reviewed. 

Recommendation 2 We recommended that the VISN Director ensure that the 

System Director requires that nurses consistently document 

the effectiveness of PRN pain medications within the 

required timeframe of the local policy. 

The VISN and System Directors concurred with the findings 

and recommendation. Nurses have been re-educated on 

documenting the effectiveness of PRN medications. In 

addition, the local medication administration policy has been 

updated. The implementation plans are acceptable, and we 

will follow up on the planned actions until they are 

completed. 

We recommended that the VISN Director ensure that the 

System Director requires that pharmacists consistently 

perform and document CLC monthly medication reviews. 

The VISN and System Directors concurred with the finding 

and recommendation. The system developed a template for 

documenting monthly CLC medication reviews. Chart 

reviews are being conducted, and data will be discussed 

monthly at Geriatric and Extended Care Committee 

meetings. The implementation plans are acceptable, and we 

will follow up on the planned actions until they are 

completed. 

Recommendation 3 

VA Office of Inspector General 5 
Combined Assessment Program Review of the VA Roseburg Healthcare System, Roseburg, Oregon 

VA Office of Inspector General 6 

Physician 

Credentialing and 

Privileging 

The purpose of this review was to determine whether VHA 

facilities have consistent processes for C&P. For a sample 

of physicians, we reviewed selected VHA required elements 

in C&P files and physician profiles.2

We reviewed 12 physicians’ C&P files and profiles and found 

that licenses were current and that primary source 

verification had been obtained. We identified the following 

area that needed improvement. 

OPPE and FPPE. The new plans for OPPE and FPPE were 

implemented August 29, 2009, and appear to be 

appropriate. However, OPPE and FPPE data for the 

12 physicians re-privileged within the last year were not 

sufficient to meet current requirements. 

Recommendation 4 We recommended that the VISN Director ensure that the 

System Director requires that the recently adopted OPPE 

and FPPE plans are fully implemented. 

The VISN and System Directors concurred with the findings 

and recommendation. The system developed a tracking 

method to identify which providers are due for FPPE or 

OPPE and to ensure timely completion of the processes. 

The implementation plans are acceptable, and we will follow 

up on the planned actions until they are completed. 

Contracted/Agency 

Registered Nurses 

The purpose of this review was to evaluate whether RNs 

working in VHA facilities through contracts or temporary 

agencies met the same entry requirements as RNs hired as 

part of VHA facility staff. We reviewed seven files of 

contracted/agency RNs who worked at the system within the 

past year. We reviewed documents for several required 

components, including background investigations, licensure, 

training, and competencies. We identified three areas that 

needed improvement. 

Training. VA and VHA require several training courses for 

staff as well as contracted/agency RNs.3 We did not find 

evidence that all mandatory training was completed. For 

example, we found no documentation of the required VHA 

information security training and VHA privacy policy training 

for three of the seven contracted/agency RNs. However, 

 

2

 VHA Handbook 1100.19, Credentialing and Privileging, November 14, 2008. 3

 VHA Directive 2007-026, Mandatory and Required Training for VHA Employees, September 17, 2007. 
Combined Assessment Program Review of the VA Roseburg Healthcare System, Roseburg, Oregon 

VA Office of Inspector General 7 

these RNs had access to VHA computer systems, which 

include patient information. 

Clinical Competence. According to local policy, 

contracted/agency RNs are expected to present documented 

evidence of current clinical competence before providing 

patient care. We found competency documentation for only 

five of the seven contracted/agency RNs. 

Background Investigations. U.S. Government agencies are 

required to complete background investigations for 

employees in sensitive positions.4 We found documentation 

of completed background investigations for six of the seven 

contracted/agency RNs. 

Recommendation 5 We recommended that the VISN Director ensure that the 

System Director requires nursing managers to validate that 

contracted/agency RNs have completed mandatory training, 

have presented evidence of clinical competence, and have 

documentation of completed background investigations prior 

to providing patient care. 

The VISN and System Directors concurred with the findings 

and recommendation. The system developed a process for 

maintaining nursing competencies, evidence of mandatory 

training, and evidence of completed background checks. 

Information will be readily available in the Nursing Service 

office. 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 Joint Commission (JC) requirements. 

Coordinated transfers, discharges, and post-discharge MH 

care are essential to an integrated, ongoing care process 

and optimal patient outcomes. 

We reviewed the documentation for 15 intra-facility transfers 

and determined that clinicians appropriately managed all 

transfers. We found transfer notes from sending to receiving 

units and documentation that nursing assessments were 

 

4

 Executive Order 10450; Security Requirements for Government Employment; April 27, 1953; Sec. 3. 
Combined Assessment Program Review of the VA Roseburg Healthcare System, Roseburg, Oregon 

performed by the receiving units in accordance with 

established timeframes. 

We reviewed the medical records of 12 patients who were 

discharged 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 three 

patients recently discharged from the locked MH unit. We 

found documentation that patients received information 

about accessing emergency MH care and that patients 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. 

Environment of 

Care 

The purpose of this review was to determine whether the 

system complied with selected infection control standards 

and maintained a clean, safe, and secure environment. VHA 

facilities are required to establish a comprehensive EOC 

program that fully meets VHA, National Center for Patient 

Safety, National Fire Protection Association, Occupational 

Safety and Health Administration, and JC standards. 

We inspected the locked MH, substance abuse, protective 

care, transitional care, inpatient medical/surgical, intensive 

care, and short stay units. We also inspected the Specialty 

Care and Primary Care White Team outpatient clinics. 

Overall, we found that the system maintained a generally 

clean and safe environment. The infection control program 

monitored exposures and reported data to clinicians for 

implementation of quality improvements. Safety guidelines 

were met, and risk assessments complied with VHA 

standards. Managers on the locked MH unit complied with 

safety regulations, and staff were trained to identify 

environmental hazards. We made no recommendations. 

Magnetic 

Resonance 

Imaging Safety 

The purpose of this review was to evaluate whether the 

system maintained a safe environment and safe practices in 

the MRI area. Safe MRI procedures minimize risk to 

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

care. 

We inspected the MRI area, examined medical and training 

records, reviewed relevant policies, and interviewed key 

VA Office of Inspector General 8 
Combined Assessment Program Review of the VA Roseburg Healthcare System, Roseburg, Oregon 

VA Office of Inspector General 9 

personnel. We determined that the system had adequate 

safety policies and had appropriately conducted a risk 

assessment of the environment, as required by The JC. 

The system had appropriate signage and barriers to prevent 

unauthorized or accidental access to the MRI area. Patients 

in the magnet room are directly observed at all times. 

Two-way communication is available between the patient 

and the MRI technologist, and the patient has access to a 

push-button call system while in the scanner. Additionally, 

mock fire and emergency response drills have been 

conducted in the MRI area. 

Local policy requires that personnel who have access to the 

MRI area receive appropriate MRI safety training. We 

reviewed the training records of 22 personnel and found that 

all had completed required safety training. 

We reviewed the medical records of 10 patients who 

received an MRI. In all cases, patients received appropriate 

screening. In addition, three patients who had an MRI with 

contrast media had signed informed consents prior to their 

procedures, in accordance with local policy. 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 on the next page shows the system’s and VISN’s overall inpatient 

satisfaction scores for quarters 1 and 2 of FY 2009. 5

 Target scores are noted on the 

graph. 

 

5

 Due to technical difficulties with VHA’s outpatient survey data, outpatient satisfaction scores for quarters 1 and 2 

of FY 2009 are not included for comparison. 
Combined Assessment Program Review of the VA Roseburg Healthcare System, Roseburg, Oregon 

40.0

45.0

50.0

55.0

60.0

65.0

70.0

75.0

80.0

85.0

90.0

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

Percent Reporting Overall Quality as Very Good or 

Excellent

Quarter Reported

Facility

VISN

INPATIENT OVERALL QUALITY

BY QUARTER

Meets

Target

Figure 1:

Employees are surveyed annually. Figure 2 below shows the system’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. 

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 10 
Combined Assessment Program Review of the VA Roseburg Healthcare System, Roseburg, Oregon 

Appendix A 

VISN Director Comments 

VA Office of Inspector General 11 

Department of 

Veterans Affairs Memorandum 

Date: December 4, 2009 

From: Director, Northwest Network (10N20) 

Subject: Combined Assessment Program Review of the VA 

Roseburg Healthcare System, Roseburg, Oregon 

To: Director, Denver Office of Healthcare Inspections (54DV) 

Director, Management Review Service (10B5) 

1. Attached is the status report for the Office of Inspector General 

Combined Assessment Program survey comments and 

implementation plan from the Roseburg VA Healthcare System, 

Roseburg, Oregon. 

2. If you have any questions regarding this report, please contact 

Jennifer Strawn, Quality Manager at (541) 440-1358. 

 (original signed by:) 

Susan Pendergrass, DrPH 
Combined Assessment Program Review of the VA Roseburg Healthcare System, Roseburg, Oregon 

Appendix B 

System Director Comments 

VA Office of Inspector General 12 

Department of 

Veterans Affairs Memorandum 

Date: December 3, 2009 

From: Director, VA Roseburg Healthcare System (653/00) 

Subject: Combined Assessment Program Review of the VA 

Roseburg Healthcare System, Roseburg, Oregon. 

To: VISN Director, Northwest Network (10N20) 

1. On behalf of the VA Roseburg Healthcare System, Roseburg, Oregon, 

I would like to express my appreciation to the Office of Inspector 

General Survey Team for their professional and comprehensive CAP 

review conducted September 21–24, 2009. 

2. We have reviewed the findings from the report. The facility responses 

addressing each recommendation are attached. The responses 

include actions that are in progress and those that have already been 

completed. 

(original signed by:) 

Susan Yeager 
Combined Assessment Program Review of the VA Roseburg Healthcare System, Roseburg, Oregon 

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 comprehensive QM program 

documentation, monitoring, tracking, and timely reporting to designated 

oversight committees. 

Concur 

Facility’s response: Following are the individual program shortfalls 

identified by the site visit team. Actions for each of these items are 

individually listed. In addition to the individual actions listed below, the 

Quality Review Council has adopted a standing agenda that meets the 

requirements of VHA Directive 2009-043, Quality Management System. 

This will help to ensure that timely data collection and analysis continues 

to occur for key processes. 

Current Basic Life Support training was not documented for 25 (5 percent) 

of 485 employees required to have life support training. 

Action: We have revised the process for monitoring BLS and ACLS: 

1. A comprehensive tracking sheet consisting of all employees who are 

required to have BLS and/or ACLS, per job responsibility, has been 

created. The tracking sheet is broken down into service level and 

month that the BLS and/or ACLS are due. 

2. Electronic correspondence is provided to both the staff and the 

supervisor to alert them when their BLS or ACLS is due. 

3. Quarterly reports of compliance and upcoming due dates are provided 

to service managers. 

4. The tracking mechanism is in place for employees who are registered 

to receive training updates but do not receive the training. 

5. Centralized scheduling has been created for the BLS and/or ACLS 

classes. 

Target Completion Date: December 31, 2009. 

Monitoring of medication reconciliation for intra-facility transfers was not 

documented until the last quarter of FY 2009. 

VA Office of Inspector General 13 
Combined Assessment Program Review of the VA Roseburg Healthcare System, Roseburg, Oregon 

Action: As noted by the OIG-CAP team at the time of the review, we 

began monitoring in the last quarter of FY 2009. Data collection is 

ongoing, and results are reported on a monthly basis to the Quality 

Management Service. 

Target Completion Date: Completed September 30, 2009. 

Moderate sedation adverse events, such as the use of assisted 

ventilation, unplanned admissions, and untoward drug events, were not 

monitored, tracked, or reported. 

The team noted that perioperative occurrences for procedures done in the 

operating room (OR) and those done outside of the OR were not 

separately tracked—they were aggregated together. Since the review, 

separate tracking mechanisms have been developed for the OR and 

non-OR occurrences. The following occurrences are being monitored: 

1. Complications. 

2. Death. 

3. Clean wound infections. 

4. Returns to the OR. 

5. Admission within 14 days of the procedure. 

6. Delays from the Post Anesthesia Care Unit to follow up care. 

7. Use of reversal agents. 

Target Completion Date: Completed October 1, 2009. 

One of four quarterly Peer Review Committee reports was not submitted 

to the Executive Committee of the Medical Staff (ECMS). 

As noted by the OIG-CAP review, three of the quarterly reports were 

submitted to the ECMS. The ECMS now has a standing agenda item to 

assure that the Peer Review Committee reports are submitted and 

reviewed on a quarterly basis. The most recent quarterly review was 

submitted November 19, 2009. 

Target Completion Date: Completed November 19, 2009. 

Three (23 percent) of 13 individual Root Cause Analysis reviews

completed in FY 2009 prior to June 2009 were not completed within 

45 days as required by VHA. 

A Tetrad member is included half-way through the RCA process to ensure 

timeliness of the analysis and appropriateness of actions, so that the 

report and recommendations can be signed by the Director or her 

surrogate in a timely manner. 

VA Office of Inspector General 14 
Combined Assessment Program Review of the VA Roseburg Healthcare System, Roseburg, Oregon 

Target Completion Date: Completed November 10, 2009. 

Two of four patient complaint reports were not submitted to a senior-level 

QM/PI committee. 

The Quality Review Council has added this quarterly report to its standing 

agenda. The next quarterly report is due November 24, 2009. 

Target Completion Date: Completed November 24, 2009. 

Recommendation 2. We recommended that the VISN Director ensure 

that the System Director requires that nurses consistently document the 

effectiveness of PRN pain medications within the required timeframe of 

the local policy. 

Concur 

Facility’s response: The Executive Council of Nurses noted this was an 

issue in June of 2009. From this assessment the following interventions 

were undertaken: 

1. Nurses have been educated on the purpose of documenting the 

effectiveness of PRN medication. 

2. Nurses are monitored on documentation of PRN effectiveness through 

on-going chart reviews. 

3. It is a standing review at the monthly Executive Council of Nurses 

meeting. 

4. We have revised MCM 1442, Medication Administration using BCMA. 

Target Completion Date: Expect 90 percent compliance by 

December 31, 2009. 

Recommendation 3. We recommended that the VISN Director ensure 

that the System Director requires that pharmacists consistently perform 

and document CLC monthly medication reviews. 

Concur 

Facility’s response: The following interventions were undertaken: 

1. A template was developed to assist the pharmacist with efficiently 

documenting review findings in the patient’s electronic medical record. 

The pharmacist is now doing this on all patients in the Community 

Living Center. 

2. This is being monitored by chart reviews, and the data is discussed 

monthly at the Geriatric and Extended Care Committee. 

Target Completion Date: Completed November 20, 2009. 

VA Office of Inspector General 15 
Combined Assessment Program Review of the VA Roseburg Healthcare System, Roseburg, Oregon 

Recommendation 4. We recommended that the VISN Director ensure 

that the System Director requires that the recently adopted OPPE and 

FPPE plans are fully implemented. 

Concur 

Facility’s response: The OPPE/FPPE policy was implemented in 

August 29, 2009. There is a spreadsheet kept by the Chief of Staff Office 

which tracks and identifies which providers are due for FPPE or OPPE. 

The service line administrator initiates and manages the OPPE/FPPE 

process. The Chief of Staff Office tracks and ensures the timeliness and 

completion of the OPPE/FPPE processes. All new hires and providers 

who request new privileges undergo FPPE. A select group of providers 

require FPPE based on defined criteria outlined in the station policy. 

Every 6 months, providers undergo OPPE. There have been 21 providers 

who have gone through the OPPE process since implementing the policy. 

As of November 30, 2009, there have been seven new providers 

privileged at the facility. One has completed the FPPE, four are in 

process, and two have not started yet. There are two providers who have 

triggered an FPPE. There are 11 providers due for OPPE during January 

through March 2010. 

Target Completion Date: Completed November 30, 2009.

Recommendation 5. We recommended that the VISN Director ensure 

that the System Director requires nursing managers to validate that 

contracted/agency RNs have completed mandatory training, have 

presented evidence of clinical competence, and have documentation of 

completed background investigations prior to providing patient care. 

Concur 

Facility’s response: The facility’s understanding, regarding the nursing 

contract, was that once the nursing contract was completed the 

documents were no longer relevant. However, the OIG consultant 

recommended keeping the records for seven years. We are following the 

recommendations and have implemented the following corrective actions: 

1. All contracted/agency nursing six-part folders will be kept for seven 

years in the Associate Chief Nurse Executive’s locked file cabinet. 

2. All contracted/agency nursing personnel will have all unit and 

service/facility competencies in their six-part folder in conjunction with 

a copy of their agency competency record. 

3. All contracted/agency nursing personnel will have in their six-part 

folder evidence of required mandatory training. 

VA Office of Inspector General 16 
Combined Assessment Program Review of the VA Roseburg Healthcare System, Roseburg, Oregon 

VA Office of Inspector General 17 

4. All contracted/agency nursing personnel will have in their six-part 

folder evidence of VHA privacy policy training and VHA information 

security training. 

5. All contracted/agency nursing personnel will have in their six-part 

folder evidence of complete background investigations. 

Target Completion Date: Completed September 25, 2009. 
Combined Assessment Program Review of the VA Roseburg Healthcare System, Roseburg, Oregon 

Appendix C 

VA Office of Inspector General 18 

OIG Contact and Staff Acknowledgments 

Contact Virginia L. Solana, Director 

Denver Office of Healthcare Inspections 

(303) 270-6501 

Contributors Ann Ver Linden, CAP Coordinator 

Linda DeLong 

Laura Dulcie 

Karen Moore 

Clarissa Reynolds 

Barry Simon 

Mary Toy 
Combined Assessment Program Review of the VA Roseburg Healthcare System, Roseburg, Oregon 

Appendix D 

VA Office of Inspector General 19 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, Northwest Network (10N20) 

Director, VA Roseburg Healthcare System (653/00) 

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: Jeff Merkley, Ron Wyden 

U.S. House of Representatives: Peter DeFazio 

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