Department of Veterans Affairs

Office of Inspector General

Office of Healthcare Inspections

Report No. 09-03039-62

Combined Assessment Program 

Review of the 

VA Sierra Nevada Health Care System 

Reno, Nevada 

January 14, 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 Sierra Nevada Health Care System, Reno, Nevada 

Table of Contents 

Page 

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

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

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

Objectives and Scope ............................................................................................. 1

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

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

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

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

Physician Credentialing and Privileging ............................................................. 5

Coordination of Care ......................................................................................... 6

Environment of Care .......................................................................................... 7

Medication Management ................................................................................... 8

Contracted/Agency Registered Nurses ............................................................. 9

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

Magnetic Resonance Imaging Safety ................................................................ 10

VHA Satisfaction Surveys ....................................................................................... 10

Appendixes

A. VISN Director Comments .................................................................................. 13

B. System Director Comments ............................................................................... 14

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

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

VA Office of Inspector General 
Combined Assessment Program Review of the VA Sierra Nevada Health Care System, Reno, Nevada 

Executive Summary 

Introduction During the week of November 2–5, 2009, the OIG conducted 

a Combined Assessment Program (CAP) review of the VA 

Sierra Nevada Health Care System (the system), Reno, NV. 

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 71 system 

employees. The system is part of Veterans Integrated 

Service Network (VISN) 21. 

Results of the 

Review 

The CAP review covered seven operational activities. We 

identified the following organizational strengths and reported 

accomplishments: 

• Discharge Call Program. 

• Provider Dashboard. 

We made recommendations in six of the activities reviewed. 

For these activities, the system needed to ensure that: 

• The patient safety manager (PSM) is added as a member 

of the Quality Executive Council (QEC). 

• An annual written adverse event disclosure report is 

provided to senior managers. 

• The privileging process complies with Veterans Health 

Administration (VHA) regulations. 

• Intra-facility transfer documentation is completed, as 

required by local policy. 

• Staff complies with local policy for multiple-dose 

medication vials. 

• PRN (as needed) pain medication effectiveness is 

consistently assessed and documented in inpatient 

medical/surgical units within the timeframe specified by 

local policy. 

• Contracted/agency registered nurses (RNs) have 

documentation of completed background investigations 

prior to providing patient care. 

VA Office of Inspector General i
Combined Assessment Program Review of the VA Sierra Nevada Health Care System, Reno, Nevada 

VA Office of Inspector General ii

The system complied with selected standards in the following 

activity: 

• Magnetic Resonance Imaging (MRI) Safety. 

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 13–17, 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 VA Sierra Nevada Health Care System, Reno, Nevada 

Introduction 

Profile Organization. The system is a tertiary care facility located 

in Reno, NV, that provides a broad range of inpatient and 

outpatient health care services. Outpatient care is also 

provided at three community based outpatient clinics in 

Fallon and Minden, NV, and in Auburn, CA. The system is 

part of VISN 21 and serves a veteran population of about 

120,000 throughout northern Nevada and northeastern 

California. 

Programs. The system provides primary care, inpatient 

medical/surgical, geriatric, and rehabilitation services. It has 

64 hospital beds and 60 community living center (CLC) beds.

Affiliations and Research. The system is affiliated with the 

University of Nevada’s School of Medicine and with the 

University of California, San Francisco’s, East Bay Surgery 

Program. Approximately 30 medical, surgical, and 

psychiatry residents rotate annually through the system. 

Additionally, the system supports pharmacy students through 

partnerships with Idaho State University, the University of 

Southern Nevada’s Schools of Pharmacy, and the American 

Society of Health Systems Pharmacists’ residency program. 

In fiscal year (FY) 2009, the system research program had 

30 projects and a budget of approximately $415,000. 

Important areas of research included pulmonary, oncology, 

and cardiac studies. 

Resources. In FY 2009, medical care expenditures totaled 

about $186 million. FY 2009 staffing was 959 full-time 

employee equivalents (FTE), including 62 physician and 

256 nursing FTE. 

Workload. In FY 2009, the system treated 27,238 unique 

patients and provided 16,448 inpatient days in the hospital 

and 19,605 inpatient days in the CLC unit. The inpatient 

care workload totaled 4,177 discharges, and the average 

daily census, including CLC patients, was 105. Outpatient 

workload totaled 303,365 visits. 

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: 

VA Office of Inspector General 1 
Combined Assessment Program Review of the VA Sierra Nevada Health Care System, Reno, Nevada 

• Conduct recurring evaluations of selected health care 

facility operations, focusing on patient care 

administration and QM.

• Provide fraud and integrity awareness training to 

increase employee understanding of the potential for 

program fraud and the requirement to refer suspected 

criminal activity to the OIG.

Scope. We reviewed selected clinical and administrative 

activities to evaluate the effectiveness of patient care 

administration and QM. Patient care administration is the 

process of planning and delivering patient care. QM is the 

process of monitoring the quality of care to identify and 

correct harmful and potentially harmful practices and 

conditions. 

In performing the review, we inspected work areas; 

interviewed managers and employees; and reviewed clinical 

and administrative records. The review covered the 

following seven activities: 

• Contracted/Agency RNs.

• Coordination of Care.

• Environment 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 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 system 

(Combined Assessment Program Review of the VA Sierra 

Nevada Health Care System, Reno, Nevada, Report 

No. 06-03484-96, March 14, 2007). The system had 

corrected all findings related to health care from our prior 

CAP review. 

During this review, we also presented fraud and integrity 

awareness briefings for 71 employees. These briefings 

covered procedures for reporting suspected criminal activity 

VA Office of Inspector General 2 
Combined Assessment Program Review of the VA Sierra Nevada Health Care System, Reno, Nevada 

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.

Organizational Strengths 

Discharge Call 

Program 

The system has recently undertaken a 100 percent 

post-discharge call back program. An RN calls each 

discharged patient within 24–48 hours after discharge. The 

RN helps the patient understand his or her health status 

changes and discharge and follow-up instructions and can 

refer the patient immediately to a pharmacist, dietician, and 

home health or specialty clinic nurse if needed. This effort 

has improved the system’s post-discharge appointment 

process, ensuring timely post-hospital follow-up. The newly 

implemented program has achieved an 81 percent patient 

contact rate.

Provider 

Dashboard 

The system has expanded the use of dashboard tools that 

are based on VHA’s dashboard, which measures 

performance based on clinical guidelines and prevention 

indicators. The system’s dashboard gives primary care 

providers (PCPs) and pharmacists 100 percent sampling of 

their patient population in the areas of diabetes, 

hyperlipidemia, and hypertension. Lists of patients not 

meeting the measures are distributed to the respective 

providers so that they can gauge their overall performance, 

track progression, and identify individual patients requiring 

intervention. The system’s dashboard supports collaborative 

drug therapy management by balancing provider access and 

patient needs. It helps clinicians manage care in the mission 

critical diseases by providing additional focused 

management and by reducing visits to PCPs. One 

significant outcome of the system’s dashboard was a 

37 percent improvement in the patient diabetic control 

measure, which improved patient access and treatment. 

VA Office of Inspector General 3 
Combined Assessment Program Review of the VA Sierra Nevada Health Care System, Reno, Nevada 

VA Office of Inspector General 4 

Results 

Review Activities With Recommendations 

Quality 

Management 

The purposes of this review were to determine 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, the QM Chief, and key personnel. To assess 

compliance with QM requirements, we reviewed the QM 

self-assessment, plans, policies, and other relevant 

documents. 

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 

initiatives. We found that 10 of the 12 areas reviewed were 

in compliance with VHA and accreditation requirements. 

However, we found opportunities for improvement in the 

following two areas. 

QM Oversight. We found that the PSM is not a member of 

the QEC. According to VHA1 and local policy, the PSM must 

be a member of the QEC. 

Adverse Event Disclosure. We found that senior managers 

do not receive an annual written report on disclosure 

information. The Joint Commission (JC) requires that senior 

managers receive a written report regarding the disclosure of 

adverse events to patients at least once a year. 

Recommendation 1 We recommended that the VISN Director ensure that the 

System Director requires that the PSM is added as a 

member of the QEC. 

The VISN and System Directors concurred with the finding 

and recommendation. The PSM is now a QEC member, and 

in December 2009, the PSM presented the annual report on 

patient safety to the QEC. The PSM will continue as a QEC 

member and will report on ongoing patient safety issues. 

 

1

 VHA Directive 2009-043, Quality Management System, September 11, 2009. 
Combined Assessment Program Review of the VA Sierra Nevada Health Care System, Reno, Nevada 

VA Office of Inspector General 5 

The corrective actions are acceptable, and we consider this 

recommendation closed. 

Recommendation 2 We recommended that the VISN Director ensure that the 

System Director requires that an annual written adverse 

event disclosure report is provided to senior managers. 

The VISN and System Directors concurred with the finding 

and recommendation. The FY 2009 adverse event 

disclosure report was presented to the Executive Leadership 

Board in writing in November 2009. This report will be 

submitted to the board annually. The corrective actions are 

acceptable, and we consider this recommendation closed. 

Physician 

Credentialing and 

Privileging 

The purpose of this review was to determine whether VHA 

facilities have consistent processes for C&P of physicians. 

For a sample of physicians, we reviewed selected VHA 

required elements in C&P files and physician profiles.2

 We 

also reviewed meeting minutes during which discussions 

about the physicians took place. 

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

that licenses were current and that primary source 

verification had been appropriately obtained. Documentation 

of provider-specific Ongoing Professional Practice 

Evaluation (OPPE) or Focused Professional Practice 

Evaluation (FPPE) data for the 10 physicians privileged or 

reprivileged within the past year was not sufficient to meet 

current requirements. We identified the following areas that 

needed improvement. 

OPPE. VHA regulations require specific competency criteria 

for OPPE for all privileged physicians. We found that for the 

2-year period prior to reprivileging, OPPE data for seven of 

the eight reprivileged physicians were not specific and did 

not support the additional privileges granted. In addition, we 

found that Medical Executive Council (MEC) minutes used 

the same standard statement for all providers and did not 

contain service chief evaluation of OPPE data to ensure 

competency prior to recommending reprivileging. 

FPPE. Also known as proctoring, FPPE is a review process 

to ensure the competence of newly hired physicians and of 

currently privileged physicians requesting new privileges. 

We reviewed the C&P files of two physicians hired in the 

 

2

 VHA Handbook 1100.19, Credentialing and Privileging, November 14, 2008. 
Combined Assessment Program Review of the VA Sierra Nevada Health Care System, Reno, Nevada 

past 12 months. We found the following: (1) the service 

chief did not recommend FPPE for the two physicians, 

(2) the timeframe for FPPE was not clearly documented, and 

(3) criteria were not developed to determine the type of 

monitoring to be conducted. 

Recommendation 3 We recommended that the VISN Director ensure that the 

System Director requires that the privileging process 

complies with VHA regulations. 

The VISN and System Directors concurred with the findings 

and recommendation. Effective December 2009, all service 

chiefs will present OPPE reports to the MEC twice a year. 

The chair of the MEC will request OPPE data on each 

physician being reviewed for renewal of privileges prior to 

the MEC completing the privileging action. Service chiefs 

will conduct FPPE for all newly privileged providers and will 

present results to the MEC at the end of each physician’s 

first 6 months of service. A generic FPPE template has been 

made available to all services, and they have been instructed 

to individualize the template for their specific needs. The 

corrective actions are acceptable, and we consider this 

recommendation closed. 

Coordination of 

Care 

The purpose of this review was to evaluate whether inpatient 

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

health (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 the medical records of discharged patients and 

found that 11 (92 percent) of the 12 records had appropriate 

documentation. In one record, the discharge instructions 

were not consistent with the discharge summary and did not 

include discharge medications. 

We also 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 

VA Office of Inspector General 6 
Combined Assessment Program Review of the VA Sierra Nevada Health Care System, Reno, Nevada 

phone within 7 days of discharge. However, we identified 

the following area that needed improvement. 

Intra-Facility Transfers. Local policy requires that a nursing 

assessment is documented by the receiving unit. We 

reviewed medical records for 12 intra-facility transfers and 

found that 4 (33 percent) of the records did not have the 

documentation required by local policy. 

Recommendation 4 We recommended that the VISN Director ensure that the 

System Director requires staff to complete intra-facility 

transfer documentation, as required by local policy. 

The VISN and System Directors concurred with the finding 

and recommendation. Patient Care Services (PCS) has 

educated nursing staff on local policy. PCS will sample 

medical records on a monthly basis to ensure compliance 

and will report results to the QEC quarterly until sustained 

improvements are demonstrated. The implementation plans 

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

until they are completed. 

Environment of 

Care 

The purpose of this review was to determine if the system 

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, and JC standards. 

We inspected all outpatient clinics, the intensive care unit 

(ICU), the inpatient medical/surgical units, the emergency 

department, the locked MH unit, and the CLC unit. We 

found that the system maintained a generally clean and safe 

environment. However, we identified the following area that 

needed improvement. 

Multiple-Dose Medication Vials. JC standards and local 

policy require that all medications are labeled with the 

contents, expiration date, and any applicable warnings and 

that they are removed when expired or damaged. In various 

refrigerators throughout the system, we found a total of 

seven multiple-dose medication vials that were open, 

outdated, or unlabeled. 

VA Office of Inspector General 7 
Combined Assessment Program Review of the VA Sierra Nevada Health Care System, Reno, Nevada 

Recommendation 5 We recommended that the VISN Director ensure that the 

System Director requires compliance with local policy 

regarding multiple-dose medication vials. 

The VISN and System Directors concurred with the findings 

and recommendation. In December 2009, the system 

implemented a “Beyond Use Date” label for all multiple-dose 

medication vials. Pharmacy staff will affix labels when the 

vials leave the pharmacy. Service chiefs have been notified, 

and they have educated their staff. Pharmacy Service will 

conduct monthly ward inspections, and a report regarding 

compliance with this new process will be presented monthly 

to the QEC. PCS will address any compliance issues. The 

corrective actions are acceptable, and we consider this 

recommendation closed. 

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 in the inpatient medical/surgical 

units, the locked MH unit, the ICU, and the CLC unit. 

We found that the system had a designated Bar Code 

Medication Administration (BCMA) Program Coordinator who 

had appropriately identified and addressed problems. We 

also found that pharmacy staff completed monthly 

medication reviews for CLC patients. However, we identified 

the following area that needed improvement. 

Pain Medication Effectiveness Documentation. Local policy 

requires that nurses assess and document the effectiveness 

of PRN pain medications within 2 hours after administration. 

We reviewed the medical records of 20 patients who 

received a total of 77 doses of pain medications. We found 

that effectiveness was appropriately documented in the ICU, 

MH, and CLC units. However, in the inpatient 

medical/surgical units, we found that only 14 (67 percent) of 

21 doses had effectiveness documented in the BCMA 

system within the timeframe required by local policy. 

Recommendation 6 We recommended that the VISN Director ensure that the 

System Director requires that inpatient medical/surgical unit 

nurses consistently assess and document PRN pain 

medication effectiveness within the timeframe specified by 

local policy. 

VA Office of Inspector General 8 
Combined Assessment Program Review of the VA Sierra Nevada Health Care System, Reno, Nevada 

VA Office of Inspector General 9 

The VISN and System Directors concurred with the findings 

and recommendation. PCS in now running PRN pain 

medication effectiveness reports, which are being monitored 

for compliance by the Nurse Executive and nurse managers. 

PCS will report results to the QEC quarterly until sustained 

improvement is demonstrated. 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 documents for 

several required components, including licensure, training, 

competencies, and background investigations. Also, we 

reviewed 10 files of contracted/agency RNs who worked at 

the system within the past year. We identified one area that 

needed improvement. 

Background Investigations. U.S. Government agencies are 

required to complete background investigations for 

employees in sensitive positions.3

 We found documentation 

of completed background investigations for 7 (70 percent) of 

the 10 contracted/agency RNs. 

Recommendation 7 We recommended that the VISN Director ensure that the 

System Director requires nursing managers to validate that 

contracted/agency RNs have documentation of completed 

background investigations prior to providing patient care. 

The VISN and System Directors concurred with the finding 

and recommendation. The system is now only using 

contracted/agency RNs who have adjudicated Special 

Agreement Checks (SAC). The PCS Contracting Officer’s 

Technical Representative will ensure that a copy of the 

e-mail with the adjudicated SAC is printed and filed prior to a 

contracted/agency RN providing patient care. PCS will 

report results to the QEC quarterly. The corrective actions 

are acceptable, and we consider this recommendation 

closed. 

 

3 Executive Order 10450, Security Requirements for Government Employment, April 27, 1953, Sec. 3. 
Combined Assessment Program Review of the VA Sierra Nevada Health Care System, Reno, Nevada 

VA Office of Inspector General 10 

Review Activities Without 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 

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 21 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, 2, and 3 of FY 2009. Figure 2 on the next page 

shows the system’s and VISN’s overall outpatient satisfaction scores for quarter 3 of 

FY 2009.4 The target scores are noted on the graphs. 

 

4

 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 Sierra Nevada Health Care System, Reno, Nevada 

VA Office of Inspector General 11 
Combined Assessment Program Review of the VA Sierra Nevada Health Care System, Reno, Nevada 

Employees are surveyed annually. Figure 3 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. 

VA Office of Inspector General 12 
Combined Assessment Program Review of the VA Sierra Nevada Health Care System, Reno, Nevada 

Appendix A 

VISN Director Comments 

VA Office of Inspector General 13 

Department of 

Veterans Affairs Memorandum 

Date: December 23, 2009 

From: Director, Sierra Pacific Network (10N21) 

Subject: Combined Assessment Program Review of the VA Sierra 

Nevada Health Care System, Reno, Nevada 

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

Director, Management Review Service (10B5) 

1. I appreciate the opportunity to review the draft report on the 

Combined Assessment Program Review of the VA Sierra Nevada 

Health Care System (VASNHCS), conducted during the week of 

November 2–5, 2009. I concur with the recommendations, and 

VASNHCS staff has completed five of the seven recommendations 

resulting from the review. We will ensure the remaining two 

recommendations are addressed and implemented as described in the 

attached plan by the established target dates. 

2. If you have any questions regarding the responses and 

actions outlined in the implementation plan, please contact 

Ms. Terry V. Sanders, VISN 21 Associate Quality Management Officer 

at (707) 562-8370. 

(original signed by:) 

Sheila M. Cullen 

Attachments 
Combined Assessment Program Review of the VA Sierra Nevada Health Care System, Reno, Nevada 

Appendix B 

System Director Comments 

VA Office of Inspector General 14 

Department of 

Veterans Affairs Memorandum 

Date: December 23, 2009 

From: Director, VA Sierra Nevada Health Care System (654/00) 

Subject: Combined Assessment Program Review of the VA Sierra 

Nevada Health Care System, Reno, Nevada 

To: Director, Sierra Pacific Network (10N21) 

1. We appreciate the opportunity to comment on the draft report of the 

Combined Assessment Program review of the VA Sierra Nevada 

Health Care System. In brief, we concur with the findings and 

suggested improvements, which are already in progress. 

2. We would like to express our thanks to the CAP review team. The 

collective interest and efforts of the CAP review team have helped 

improve our organizational practices at VASNHCS. 

 (original signed by:) 

Kurt W. Schlegelmilch, M.D., FACHE 
Combined Assessment Program Review of the VA Sierra Nevada Health Care System, Reno, Nevada 

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 the PSM is added as a member of 

the QEC. 

Concur 

Facility’s Response: The Patient Safety Manager was added back to the 

Quality Executive Council on November 5, 2009. On December 15, 2009, 

the PSM presented the annual report on Patient Safety to the Council. 

The PSM will continue to be a member of this Council and will report on 

ongoing patient safety issues. 

Target Completion Date: Completed December 15, 2009. 

Recommendation 2. We recommended that the VISN Director ensure 

that the System Director requires that an annual written adverse event 

disclosure report is provided to senior managers. 

Concur 

Facility’s Response: The FY 2009 Adverse Events Disclosure report 

was presented (verbally and in writing) to the Executive Leadership Board 

on November 23, 2009. This will be done annually. 

Target Completion Date: Completed November 23, 2009. 

Recommendation 3. We recommended that the VISN Director ensure 

that the System Director requires that the privileging process complies 

with VHA regulations. 

Concur 

Facility’s Response: The Ongoing Professional Practice Evaluation 

process was in place at the time of the Office of Inspector General survey, 

but it was not consistently implemented by all Service Chiefs. Effective 

December 1, 2009, OPPE reports will be presented to the Medical 

Executive Council (MEC) twice a year by all Service Chiefs. The chair of 

MEC will request the OPPE on each person being reviewed for renewal of 

VA Office of Inspector General 15 
Combined Assessment Program Review of the VA Sierra Nevada Health Care System, Reno, Nevada 

privileges. This is mandatory for renewal and will be required prior to the 

MEC completing the privileging action. 

Effective December 21, 2009, Focused Professional Practice Evaluation 

will be conducted by Service Chiefs for all newly privileged physicians and 

presented to MEC at the end of a physician’s first six months of service. 

This generic template is made available for all services, and they are 

instructed to individualize the form for their specific Services and individual 

physician’s privileges. 

Target Completion Date: Completed December 21, 2009. 

Recommendation 4. We recommended that the VISN Director ensure 

that the System Director requires staff to complete intra-facility transfer 

documentation, as required by local policy. 

Concur 

Facility’s Response: As of December 21, 2009, Patient Care Services 

has educated nursing staff as to the local policy. Patient Care Services is 

monitoring, on a monthly basis, a sampling of medical records to ensure 

compliance with local policy, and following up with staff that are not 

compliant. Patient Care Service will report this information to Quality 

Executive Council on a quarterly basis until sustained improvements are 

demonstrated, and then the frequency of monitoring will be revised. The 

quarter one, FY 2010 results will be reported to Quality Executive Council 

on January 19, 2010. 

Target Completion Date: January 19, 2010. 

Recommendation 5. We recommended that the VISN Director ensure 

that the System Director requires compliance with local policy regarding 

multiple-dose medication vials. 

Concur 

Facility’s Response: Effective December 1, 2009, the system 

implemented a “Beyond Use Date” label for all multi-dose vials. The label 

with this date is being applied by Pharmacy staff when the vial leaves the 

pharmacy. Service Chiefs have received notification from Pharmacy 

regarding this change and have educated their staff. Ward inspections will 

be completed monthly by Pharmacy Service, and a report of compliance 

with the new process will be given monthly in Quality Executive Council 

beginning January 19, 2010. Patient Care Services will address any 

issues with compliance upon receipt of this report. 

Target Completion Date: Completed December 1, 2009. 

VA Office of Inspector General 16 
Combined Assessment Program Review of the VA Sierra Nevada Health Care System, Reno, Nevada 

VA Office of Inspector General 17 

Recommendation 6. We recommended that the VISN Director ensure 

that the System Director requires that inpatient medical/surgical unit 

nurses consistently assess and document PRN pain medication 

effectiveness within the timeframe specified by local policy. 

Concur 

Facility’s Response: Effective December 21, 2009, Patient Care Service 

is running the pain PRN effectiveness reports, which are monitored for 

compliance by the Nurse Executive and Nurse Managers. Nurse 

Managers will intervene with staff as needed, as identified in the 

monitoring. Patient Care Service will report this information to Quality 

Executive Council on a quarterly basis until sustained improvement is 

demonstrated, then the frequency of monitoring will be revisited. The 

Quarter 1, FY 2010 report will be given in the Quality Executive Council on 

January 19, 2010. 

Target Completion Date: January 19, 2010. 

Recommendation 7. We recommended that the VISN Director ensure 

that the System Director requires nursing managers to validate that 

contracted/agency RNs have documentation of completed background 

investigations prior to providing patient care. 

Concur 

Facility’s Response: No new contracted/agency RNs have started 

employment at VASNHCS since the CAP review. Patient Care Service is 

not utilizing any contracted/agency registered nurses who do not have an 

adjudicated SAC, including those nurses cited by the Office of Inspector 

General surveyors. Prior to contracted/agency registered nurses coming 

on station to provide patient care, Patient Care Services COTR will ensure 

a copy of the email with the adjudicated SAC will be printed and filed in 

the Service. Patient Care Service will report this information to Quality 

Executive Council on a quarterly basis until sustained improvement has 

been demonstrated, then the frequency of monitoring will be revisited. 

Target Completion Date: Completed November 5, 2009.
Combined Assessment Program Review of the VA Sierra Nevada Health Care System, Reno, Nevada 

Appendix C 

VA Office of Inspector General 18 

OIG Contact and Staff Acknowledgments 

Contact Virginia L. Solana, Director 

Denver Office of Healthcare Inspections 

(303) 270-6500 

Contributors Clarissa B. Reynolds, Team Leader 

Laura Dulcie 

Ann Ver Linden 

Barry L. Simon 

Cheryl A. Walker 

Toni Woodard 

Michael Seitler, Office of Investigations 
Combined Assessment Program Review of the VA Sierra Nevada Health Care System, Reno, Nevada 

Appendix D 

VA Office of Inspector General 19 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, Sierra Pacific Network (10N21) 

Director, VA Sierra Nevada Health Care System (654/00) 

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: John Ensign, Harry Reid 

U.S. House of Representatives: Dean Heller 

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