Department of Veterans Affairs

Office of Inspector General

Office of Healthcare Inspections

Report No. 08-03074-101

Combined Assessment Program 

Review of the 

Lexington VA Medical Center 

Lexington, Kentucky 

March 31, 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 Lexington VA Medical Center, Lexington, Kentucky 

Table of Contents 

Page 

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

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

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

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

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

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

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

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

Emergency/Urgent Care Operations ................................................................. 8

Medication Management ................................................................................... 10

Review Activities Without Recommendations ......................................................... 11

Environment of Care.......................................................................................... 11

Pharmacy Operations........................................................................................ 11

Staffing .............................................................................................................. 12

Survey of Healthcare Experiences of Patients .................................................. 13

Appendixes

A. VISN Director Comments .................................................................................. 15

B. Medical Center Director Comments................................................................... 16

C. OIG Contact and Staff Acknowledgments ......................................................... 22

D. Report Distribution............................................................................................. 23

VA Office of Inspector General 
Combined Assessment Program Review of the Lexington VA Medical Center, Lexington, Kentucky 

Executive Summary 

Introduction During the week of November 3–7, 2008, the OIG conducted 

a Combined Assessment Program (CAP) review of the 

Lexington VA Medical Center (the medical center), 

Lexington, KY. 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 91 medical 

center employees. The medical center is part of Veterans 

Integrated Service Network (VISN) 9. 

Results of the 

Review 

The CAP review covered eight operational activities. We 

made recommendations in four of the activities reviewed. 

For these activities, the medical center needed to require 

that: 

• Root cause analysis (RCA) actions be monitored, 

measurable, and evaluated for effectiveness. 

• Data on resuscitation events and outcomes be discussed, 

analyzed, and compared over time to identify opportunities 

for improvement. 

• Medical record reviews be completed in accordance with 

Veterans Health Administration (VHA) policy and that 

deficiencies be addressed. 

• Performance improvement (PI) data is collected, analyzed, 

and used to support decisions during the reprivileging 

process. 

• Discharge instructions, discharge summaries, and 

physician orders be consistent. 

• All inter-facility transfer documentation complies with VHA 

policy. 

• A system be developed to assure that all emergency 

department (ED) nursing staff competencies are 

completed and documented annually. 

• Nurses consistently document the effectiveness of all pain 

medications within the timeframe established by local 

policy. 

The medical center complied with selected standards in the 

following four activities: 

• Environment of Care (EOC). 

VA Office of Inspector General i
Combined Assessment Program Review of the Lexington VA Medical Center, Lexington, Kentucky 

• Pharmacy Operations. 

• Staffing. 

• Survey of Healthcare Experiences of Patients (SHEP). 

This report was prepared under the direction of 

Victoria Coates, Director, Atlanta Office of Healthcare 

Inspections. 

Comments The VISN and Medical Center Directors agreed with the CAP 

review findings and recommendations and provided 

acceptable improvement plans. (See Appendixes A and B, 

pages 15–21, 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 

VA Office of Inspector General ii
Combined Assessment Program Review of the Lexington VA Medical Center, Lexington, Kentucky 

VA Office of Inspector General 1 

Introduction 

Profile Organization. The medical center is a two-division (Cooper 

and Leestown) tertiary care facility located in Lexington, KY, 

that provides a broad range of inpatient and outpatient health 

care services. Outpatient care is also provided at four 

community based outpatient clinics (CBOCs) in Somerset, 

Morehead, Hazard, and Berea, KY. The medical center is 

part of VISN 9 and serves a veteran population of about 

92,000 throughout 37 counties in central and eastern 

Kentucky. 

Programs. The medical center provides medical, surgical, 

mental health, rehabilitation, and community living center 

(CLC)1

 services. It has 99 hospital beds and 61 CLC beds 

and operates several regional referral programs, including 

residential rehabilitation treatment programs for both 

post-traumatic stress disorder and substance abuse. The 

medical center also serves as the Polytrauma Network Site 

for VISN 9. 

Affiliations and Research. The medical center is affiliated 

with the University of Kentucky and with 31 other colleges 

and universities. It provides training for 84 medical residents, 

as well as other disciplines, including nursing, respiratory 

therapy, psychology, pharmacy, health administration, 

optometry, social work, and dietetics. In fiscal year 

(FY) 2008, the medical center research program had 

95 projects and a budget of $4 million. Important areas of 

research included thyroid and prostate cancer and 

type 2 diabetes. 

Resources. In FY 2008, medical care expenditures totaled 

approximately $256.8 million. The FY 2009 medical care 

budget is approximately $225.7 million. FY 2008 staffing was 

1,612 full-time employee equivalents (FTE), including 

95 physician and 336 nursing FTE. 

Workload. In FY 2008, the medical center treated 

33,675 unique patients and provided 28,144 inpatient days in 

the hospital and 18,221 inpatient days in the CLC. The 

inpatient workload totaled 5,914 discharges, and the average 

 

1

 A CLC (formerly called a nursing home care unit) provides a homelike environment to eligible veterans who 

require a nursing home level of care. 
Combined Assessment Program Review of the Lexington VA Medical Center, Lexington, Kentucky 

daily census, including CLC patients, was 127. Outpatient 

workload totaled 351,801 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: 

• 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.

• QM Program.

• SHEP.

• Staffing.

The review covered medical center operations for FY 2007, 

FY 2008, and FY 2009 through November 7, 2008, and was 

done in accordance with OIG standard operating 

procedures for CAP reviews. We followed up on select 

recommendations from our prior CAP review of the medical 

center (Combined Assessment Program Review of the 

VA Office of Inspector General 2 
Combined Assessment Program Review of the Lexington VA Medical Center, Lexington, Kentucky 

VA Medical Center, Lexington, Kentucky, Report 

No. 06-00012-49, January 5, 2006). The medical center had 

corrected all findings related to health care from our prior 

CAP review. 

We also followed up on recommendations from a report by 

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

Quality of Care Review of the Delivery of Surgical Care, 

Lexington, Kentucky, August 27, 2008.) In that report, the 

OMI made recommendations to improve documentation of 

physician involvement and decision making in surgical care, 

improve meeting minutes associated with surgical care, and 

ensure that providers receive due process in credentialing 

and privileging (C&P) actions. We reviewed the medical 

center’s follow-up documentation and plans in response to 

the OMI recommendations. We found the medical center’s 

actions to be appropriate, and we consider the OMI 

recommendations closed. 

During this review, we also presented fraud and integrity 

awareness briefings to 91 employees. These briefings 

covered procedures for reporting suspected criminal activity 

to the OIG and included case-specific examples illustrating 

procurement fraud, conflicts of interest, and bribery. 

In this report, we make recommendations for improvement. 

Recommendations pertain to issues that are significant 

enough to be monitored by the OIG until corrective actions 

are implemented. Activities in the “Review Activities Without 

Recommendations” section have no findings requiring 

corrective actions.

Results 

Review Activities With Recommendations 

Quality 

Management 

Program 

The purpose of this review was to evaluate whether the 

medical center had a comprehensive QM program designed 

to monitor patient care quality and whether senior managers 

actively supported the program’s activities. We evaluated 

policies, PI data, and other relevant documents, and we 

interviewed appropriate senior managers and the QM 

Coordinator. 

The QM program was generally effective, and senior 

managers supported the program through participation in 

and evaluation of PI initiatives and through allocation 

VA Office of Inspector General 3 
Combined Assessment Program Review of the Lexington VA Medical Center, Lexington, Kentucky 

VA Office of Inspector General 4 

of resources to the program. Appropriate review structures 

were in place for 11 of the 15 program activities reviewed. 

However, we identified four areas that needed improvement. 

Root Cause Analysis. We found that elements of the RCA 

process did not comply with VHA guidelines. RCAs are 

designed to identify and resolve the root cause of system 

and/or process deficiencies involved in an actual or potential 

adverse event. VHA policy2 requires that corrective actions 

be evaluated for effectiveness and that outcomes be 

measurable. This approach allows managers to assess 

whether the actions had the desired effect in improving, 

controlling, or eliminating the root cause of the condition. 

The medical center completed a total of 10 RCAs (individual 

and aggregate) between October 2007 and September 2008. 

In these 10 RCAs, there were 21 issues identified that 

required corrective actions. We found that in 18 (86 percent) 

of the 21 issues, corrective actions were not monitored for 

effectiveness, and outcome measures were either not 

measurable or were not documented at all. For example, one 

corrective action included training mental health staff on the 

utilization of the Rapid Response Team. Although training 

was completed, the outcome measure of staff knowledge was 

not assessed. Without evaluation of corrective actions and 

documentation of outcome measures, managers could not 

determine whether the expected outcomes were achieved 

and the root causes were addressed. 

Resuscitation Outcome Analysis. We found that the Critical 

Care Committee did not discuss cardiopulmonary 

resuscitation (CPR) events and their outcomes. CPR is a 

life-saving process for patients who suffer a cardiac arrest. 

External accreditation standards require that data on 

resuscitation events and outcomes be aggregated, analyzed, 

and compared over time (either internally or externally) to 

identify opportunities for improvement. 

To obtain appropriate benchmark data, the medical center 

submits data to the National Registry of CardioPulmonary 

Resuscitation (NRCPR) on all of its CPR events. The 

NRCPR then provides quarterly reports, including benchmark 

data, back to the medical center. Despite the availability of 

data, the Critical Care Committee did not discuss, analyze, or 

compare CPR data over time to identify existing trends or 

 

2

 VHA Handbook 1050.01, VHA National Patient Safety Improvement Handbook, May 23, 2008. 
Combined Assessment Program Review of the Lexington VA Medical Center, Lexington, Kentucky 

VA Office of Inspector General 5 

potential problems. Without analysis, managers could not be 

assured that CPR was performed correctly and timely and 

that problems were addressed. 

Medical Record Reviews. We found that services did not 

regularly conduct medical record reviews to monitor 

appropriate documentation, as required by VHA policy.3 In 

addition, results of reviews conducted were not reported to 

the Medical Records Committee (MRC). VHA policy requires 

ongoing medical record reviews to assess the quality, 

consistency, accuracy, completeness, and authentication4 of 

medical record entries. Results of record reviews, findings 

from record completion monitors, and delinquent record 

statistics must be reported to the MRC. Without this 

information, the committee could not aggregate data, identify 

variances, and make recommendations for improvement in 

the documentation of patient care. 

In FY 2008, the MRC identified 57 percent of physician 

orders and 25 percent of progress notes as delinquent.5

 This 

information was not forwarded to the Medical Staff 

Committee, and we found no evidence that corrective actions 

were taken. Without complete medical record entries, 

managers could not be assured that relevant patient care and 

treatment information was available to clinicians. 

Provider Performance Monitoring. VHA regulations 6

require that clinical managers develop plans for continuous 

performance monitoring of the medical staff. According to 

requirements, collection of individual performance data should 

be ongoing, include indicators for continuing qualifications 

and competencies, and be reviewed and considered during 

the reprivileging process. At the time of our review, we found 

that clinical leaders had completed the C&P training modules 

and had developed plans for ongoing physician competency 

monitoring. However, we found that for providers 

reprivileged in the past 12 months, 24 (80 percent) of 

the 30 C&P folders did not contain adequate 

performance and corresponding PI data to support the 

privileges granted. Without adequate evaluation of provider 

performance, managers could not be assured that clinical 

interventions met standards of practice. 

 3

 VHA Handbook 1907.01, Health Information Management and Health Records, August 25, 2006. 4

 Authenticated entries include the date and time and the signature of practitioner. 5

 Delinquent entries have not been authenticated and have failed to meet timeliness standards. 

6

 VHA Handbook 1100.19, Credentialing and Privileging, October 2, 2007. 
Combined Assessment Program Review of the Lexington VA Medical Center, Lexington, Kentucky 

Recommendation 1 We recommended that the VISN Director ensure that the 

Medical Center Director requires that RCA actions be 

monitored, measurable, and evaluated for effectiveness. 

The VISN and Medical Center Directors agreed with the 

findings and recommendation. The medical center 

developed an internal process to ensure that RCA actions are 

strong and that outcome measures are quantifiable. This will 

allow managers to evaluate effectiveness. The 

implementation plans are acceptable, and we will follow up 

on the planned actions until they are completed. 

Recommendation 2 We recommended that the VISN Director ensure that the 

Medical Center Director requires that data on resuscitation 

events and outcomes be discussed, analyzed, and compared 

over time to identify opportunities for improvement. 

The VISN and Medical Center Directors agreed with the 

findings and recommendation. A critical care nurse specialist 

is now responsible for maintaining the NRCPR database and 

providing monthly reports to the Critical Care Committee. 

Oversight of the Critical Care Committee is now assigned to 

the Clinical Executive Council, which is chaired by the Chief 

of Staff. The implementation plans are acceptable, and we 

will follow up on the planned actions until they are completed. 

Recommendation 3 We recommended that the VISN Director ensure that the 

Medical Center Director requires that medical record reviews 

be completed in accordance with VHA policy and that 

deficiencies be addressed. 

The VISN and Medical Center Directors agreed with the 

findings and recommendation. The medical center is 

developing reporting matrices to summarize all ongoing 

point-of-care and medical record reviews. The medical 

record review matrix will include timeliness of progress note 

and order signatures. Point-of-care and medical record 

reviews are being added to the MRC agenda template as 

monthly recurring report items. Findings, actions, and 

recommendations will also be reviewed and/or addressed by 

the Clinical Executive Council. The implementation plans are 

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

they are completed. 

Recommendation 4 We recommended that the VISN Director ensure that the 

Medical Center Director requires that provider PI data is 

VA Office of Inspector General 6 
Combined Assessment Program Review of the Lexington VA Medical Center, Lexington, Kentucky 

collected, analyzed, and used to support decisions during the 

reprivileging process. 

The VISN and Medical Center Directors agreed with the 

findings and recommendation. The medical center is 

developing standardized, provider-specific report cards that 

will be used by all services for reprivileging decisions. In 

addition, the medical center revised the Professional 

Standards Board meeting minutes template to include 

ongoing practice evaluation information. The implementation 

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

actions until they are completed. 

Coordination of 

Care 

The purpose of this review was to evaluate whether selected 

aspects of care, such as consultations, intra-facility transfers, 

and discharges, were coordinated appropriately over the 

continuum of care. Timely responses to consultations, 

effective management of patient transfers, and appropriate 

discharge instructions are essential to optimal patient 

outcomes. 

We reviewed randomly selected records for the 4th quarter of 

FY 2008. We found timely responses for all 12 of the 

inpatient consultations we reviewed, and in all cases, nursing 

assessments had been completed within the required 

timeframes. In addition, we reviewed medical records of 

patients who transferred between units. In 11 (92 percent) of 

the 12 records reviewed, we found consistent and timely 

patient assessments by receiving unit nursing staff. We 

identified one area that needed improvement. 

Discharge Documentation. We found that medical record 

discharge documentation was inconsistent. There were 

inconsistencies between patient discharge instructions, 

discharge summaries, and physician orders in 7 (58 percent) 

of the 12 medical records we reviewed. In all seven records, 

the nursing discharge instruction sheet templates listed some 

medications that had been discontinued at the time of 

discharge. Two of these records also contained incorrect 

discharge diet orders. Additionally, we found that 

5 (42 percent) of the 12 records had medication 

inconsistencies between patient discharge summaries and 

physician orders. Without consistency in discharge 

documentation, patient safety can be at risk. Conflicting 

instructions could be confusing to patients and other care 

VA Office of Inspector General 7 
Combined Assessment Program Review of the Lexington VA Medical Center, Lexington, Kentucky 

providers and increase the probability of non-compliance or 

an adverse event. 

We noted that the medical center had recently expanded the 

medication reconciliation program to include reconciliation at 

discharge with a pharmacist providing bedside discharge 

counseling and education. This process is aimed at lowering 

the percentage of unreconciled medications. 

Recommendation 5 We recommended that the VISN Director ensure that the 

Medical Center Director requires that discharge instructions, 

discharge summaries, and physician orders be consistent. 

The VISN and Medical Center Directors agreed with the 

findings and recommendation. The medical center is 

developing a standardized pharmacy note template, which 

will include key regulatory requirements. This note will be 

printed and given to the patient prior to discharge. In 

addition, to ensure consistent discharge medication 

information, medication lists will no longer be imported into 

discharge summaries or discharge nursing notes. The 

implementation plans are acceptable, and we will follow up 

on the planned actions until they are completed. 

Emergency/Urgent 

Care Operations 

The purpose of this review was to evaluate selected aspects 

of the ED, such as clinical services, consultations, 

inter-facility transfers, staffing, and staff competencies. 

We interviewed ED physicians, the ED program manager, 

and other Critical Care Service Line staff. We reviewed 

policies and other pertinent documents, including 

competency files and C&P folders. We also reviewed 

selected medical records of patients who had consultations to 

other services and who were transferred from the ED to other 

medical facilities. 

The ED is located in the main hospital building at the Cooper 

division and is open 24 hours per day, 7 days per week, as 

required for an ED. Emergency services provided are within 

the medical center’s patient care capabilities. Also, the 

medical center has a procedure in place for the management 

of patients whose care may exceed the medical center’s 

capability. 

We conducted EOC tours and found that the environment 

was clean and safe and that equipment was appropriately 

VA Office of Inspector General 8 
Combined Assessment Program Review of the Lexington VA Medical Center, Lexington, Kentucky 

VA Office of Inspector General 9 

maintained. However, we identified the following conditions 

that needed improvement: 

Inter-Facility Transfers. Patient transfer documentation did 

not consistently comply with VHA policy.7 We reviewed the 

medical records of three patients who were transferred to 

other facilities. We were unable to find transfer orders or 

evidence of physician-to-physician handoff communication for 

any of the three patients. Without proper documentation, 

managers could not be assured that continuity of patient care 

had been achieved. 

Emergency Department Nurse Competency Assessments.

We found completed unit-based competency assessments 

for FY 2008 for three randomly selected nursing files we 

reviewed; however, we were unable to find competency 

evaluations for FYs 2005, 2006, and 2007. Medical center 

policy requires that nurse competencies be completed 

annually. Without competency assessments, medical center 

managers could not be assured that ED nurses had the skills 

necessary to safely and appropriately perform patient care 

activities. 

Recommendation 6 We recommended that the VISN Director ensure that the 

Medical Center Director requires that all inter-facility transfer 

documentation comply with VHA policy. 

The VISN and Medical Center Directors agreed with the 

findings and recommendation. The medical center 

implemented a process to ensure that inter-facility transfer 

documentation is completed, as required. The process is 

being monitored, data is being aggregated, and findings will 

be reported to the Clinical Executive Council. The 

implementation plans are acceptable, and we will follow up 

on the planned actions until they are completed. 

Recommendation 7 We recommended that the VISN Director ensure that the 

Medical Center Director develops a system to assure that all 

ED nursing staff competencies are evaluated and 

documented annually. 

The VISN and Medical Center Directors agreed with the 

finding and recommendation. The medical center has 

changed the process for filing nurse competencies. Copies 

of competencies are now retained by responsible nurse 

 

7

 VHA Directive 2007-015, Inter-Facility Transfer Policy, May 7, 2007. 
Combined Assessment Program Review of the Lexington VA Medical Center, Lexington, Kentucky 

managers, attached to annual proficiency reports, and filed in 

the official personnel records. 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 adequate medication management practices. A 

safe medication management system includes medication 

ordering, administering, and monitoring. 

We reviewed selected medication management processes on 

the inpatient acute medical/surgical, mental health, and 

intensive care units. We found adequate management of 

medications brought into the facility by patients or their 

families. Nurses appropriately scanned patient armbands 

and used personal identifiers to correctly identify patients 

prior to medication administration. Also, we found that 

reconciliation of controlled substances discrepancies at the 

unit level was adequate. We identified one area that needed 

improvement. 

Documentation of Pain Medication Effectiveness. We found 

that documentation of pain medication effectiveness did not 

comply with local policy. We reviewed 18 administered 

doses of PRN (as needed) pain medication. We found 

effectiveness documented within 1 hour, as required by local 

policy, for only four (22 percent) of the doses. For the 

remaining doses, the times between medication 

administration and the evaluation of effectiveness ranged 

from 139 to 434 minutes. Without appropriate follow-up and 

consistent documentation, clinicians could not be assured 

that patients’ pain was effectively managed. 

Recommendation 8 We recommended that the VISN Director ensure that the 

Medical Center Director requires that nurses consistently 

document the effectiveness of all pain medications within the 

timeframe established by local policy. 

The VISN and Medical Center Directors agreed with the 

findings and recommendation. The medical center 

implemented an automated monitoring approach for PRN 

effectiveness documentation. Feedback is provided to unit 

managers and staff nurses weekly. Aggregated data and 

results will be reported to the Clinical Executive Council for 

review, discussion, and action, as appropriate. The 

VA Office of Inspector General 10 
Combined Assessment Program Review of the Lexington VA Medical Center, Lexington, Kentucky 

VA Office of Inspector General 11 

implementation plans are acceptable, and we will follow up 

on the planned actions until they are completed. 

Review Activities Without Recommendations 

Environment of 

Care 

The purpose of this review was to determine whether the 

medical center maintained a safe and clean health care 

environment. Medical centers are required to provide a 

comprehensive EOC program that fully meets VHA, 

Occupational Safety and Health Administration, and external 

accreditation standards. 

We inspected the locked mental health unit (4S), the CLC, an 

acute care unit (3S), the progressive care unit, and the 

intensive care unit. The medical center maintained a 

generally clean and safe environment. Infection control 

program staff monitored and reported data to clinicians for 

implementation of quality improvements. Safety guidelines 

were met, and risk assessments complied with VHA 

standards. Furthermore, managers on the locked mental 

health unit complied with safety regulations, and staff were 

trained to identify environmental hazards. 

During our tour, we found that suicide prevention posters 

were not consistently displayed in designated high-visibility 

areas, dirty linen hampers were stored in a hydrotherapy 

room on unit 3S, and nurse call buttons located in patient 

rooms on 4S were inoperable. Because managers took 

immediate actions to address these deficiencies while we 

were onsite, we made no recommendations. 

Pharmacy 

Operations 

The purpose of this review was to evaluate whether VHA 

facilities had adequate controls to ensure the security and 

proper management of controlled substances and the safety 

and security of the inpatient and outpatient pharmacies’ 

internal physical environments. We also assessed whether 

clinical managers had processes in place to monitor patients 

for polypharmacy. 

We evaluated whether the medical center’s policies and 

practices were consistent with VHA regulations8

 governing 

pharmacy and controlled substances security. We inspected 

inpatient and outpatient pharmacies for security, EOC, and 

 

8

 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. 
Combined Assessment Program Review of the Lexington VA Medical Center, Lexington, Kentucky 

VA Office of Inspector General 12 

infection control issues. We interviewed appropriate 

Pharmacy Service staff and Police and Security Service 

personnel. 

Pharmacy Controls. The medical center had appropriate 

policies and procedures to ensure the security of controlled 

substances and to ensure the safety and security of the 

pharmacies’ physical environments. Training records 

showed that the Controlled Substances Coordinator and 

controlled substances inspectors received appropriate 

training to execute their duties. We found that the 

pharmacies were secure, clean, and well maintained. 

Polypharmacy. Pharmacological regimens involving multiple 

medications are often necessary to prevent and control 

disease states; however, excessive use of medications can 

result in adverse reactions and increased risk 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.9 

We interviewed pharmacy clinical managers to determine the 

medical center’s efforts to monitor and avoid inappropriate 

polypharmacy. Clinical pharmacists identified patients who 

were prescribed multiple medications, reviewed the 

medication regimens to avoid complications related to 

polypharmacy, and advised providers regarding potential 

polypharmacy complications when appropriate. 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 and actual staffing for the 

ED, an acute care unit, the intensive care unit, and the CLC. 

We found that guidelines were met and that specific actions 

had been taken to ensure patient safety, including 

 

9

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

December 2004. 
Combined Assessment Program Review of the Lexington VA Medical Center, Lexington, Kentucky 

VA Office of Inspector General 13 

cross-coverage by staff and the use of a nurse registry. We 

made no recommendations. 

Survey of 

Healthcare 

Experiences of 

Patients 

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

facilities use SHEP data to improve patient care, treatment, 

and services. The SHEP program is aimed at capturing 

patient perceptions of care in 12 service areas, including 

access to care, coordination of care, and courtesy. VHA 

relies on the Office of Quality and Performance’s analysis of 

the survey data to improve the quality of care delivered to 

patients. VHA’s Executive Career Field Performance Plan 

states that at least 76 percent of inpatients discharged during 

a specified date range and 77 percent of outpatients treated 

will report the overall quality of their experiences as “very 

good” or “excellent.” Facilities are expected to address areas 

in which they are underperforming. 

The graphs shown below and on the next page show the 

medical center’s performance in relation to national and VISN 

performance. Figure 1 shows the medical center’s SHEP 

performance measure results for inpatients, and Figure 2 

shows the medical center’s SHEP performance measure 

results for outpatients. 

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) Qtr 3 (FY 08)

Quarter Reported

Percent Reporting Overall Quality as Very Good or Excellent

Facility

VISN

National

Lexington VA Medical Center

INPATIENT OVERALL QUALITY

BY QUARTER

Meets 

Target

Figure 1:
Combined Assessment Program Review of the Lexington VA Medical Center, Lexington, Kentucky 

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) Qtr 3 (FY 08)

Quarter Reported

Percent Reporting Overall Quality as Very Good or Excellent

Facility

VISN

National

Lexington VA Medical Center

OUTPATIENT OVERALL QUALITY

BY QUARTER

Figure 2:

Meets 

Target

The medical center met or exceeded the established target 

for inpatient overall quality in 4 of the last 8 quarters and met 

or exceeded the target for outpatient overall quality in 5 of the 

last 8 quarters. 

The medical center had a multidisciplinary Patient 

Satisfaction Committee that analyzed and reported SHEP 

survey results. Managers had initiated improvement actions, 

which included creating a Pharmacy call center, initiating 

service recovery, providing Disney Institute training, and 

implementing other goal sharing activities. The medical 

center’s improvement plan, corrective actions, and recent 

internal patient satisfaction scores demonstrated positive 

impact; therefore, we made no recommendations. 

VA Office of Inspector General 14 
 Combined Assessment Program Review of the Lexington VA Medical Center, Lexington, Kentucky 

Appendix A 

VISN Director Comments 

VA Office of Inspector General 15 

Department of 

Veterans Affairs Memorandum 

Date: February 18, 2009 

From: Network Director (10N9), VA Mid South Healthcare Network 

Subject: Combined Assessment Program Review of the 

Lexington VA Medical Center, Lexington, Kentucky 

To: Director, Atlanta Office of Healthcare Inspections (54AT) 

Director, Management Review Service (10B5) 

1. I concur with the findings and recommendations of this Office of 

Inspector General Combined Assessment Program Review of the 

Lexington VA Medical Center as well as the action plan developed by the 

facility. 

2. If you have questions or require additional information from the 

Network, please do not hesitate to contact Pamela Kelly, Staff Assistant to 

the Network Director, at 615-695-2205 or me at 615-695-2206. 

 (original signed by:) 

John Dandridge, Jr. 
Combined Assessment Program Review of the Lexington Medical Center, Lexington, Kentucky 

Appendix B 

Medical Center Director Comments 

VA Office of Inspector General 16 

Department of 

Veterans Affairs Memorandum 

Date: February 16, 2009 

From: Director, VA Medical Center, Lexington, KY (596/00) 

Subject: Combined Assessment Program Review of the 

Lexington VA Medical Center, Lexington, Kentucky 

To: Director, VA Mid South Healthcare Network (10N9) 

1. On behalf of the Lexington VA Medical Center, I concur with the 

findings and recommendations of this Office of Inspector General report. 

We had already been actively working to improve or enhance several of 

these areas and welcome the “fresh eyes” perspective provided by this 

report. 

2. Included herein is an outline of improvement actions already taken, in 

progress, or planned in response to these findings. We believe these 

changes will further enhance key systems and processes in our medical 

center. 

 (original signed by:)

Sandy J. Nielsen, FACHE 
 Combined Assessment Program Review of the Lexington VA Medical Center, Lexington, Kentucky 

Comments to Office of Inspector General’s Report 

The following Director’s comments are submitted in response to the 

recommendations in the Office of Inspector General report: 

OIG Recommendations

Recommendation 1. We recommended that the VISN Director ensure 

that the Medical Center Director requires that RCA actions be monitored, 

measurable, and evaluated for effectiveness. 

Concur 

Lexington was one of 37 VA facilities to be recognized with bronze level 

RCA Cornerstone Recognition by the National Center for Patient Safety in 

2008 and was already committed to achieving the gold level in 2009. 

Requirements for this include having strong RCA actions with quantifiable 

outcome measures. Our most recent RCA was critiqued by the National 

Center for Patient Safety (NCPS) with concurrence of strong action and 

quantifiable outcome. The root cause action and outcome submitted 

were: 

• Root Cause: Lack of explicit assessment criteria defining 

elopement risks increased the likelihood that patients would not be 

properly assessed and closely monitored and increases the risk of 

patient elopements. 

• Action: Standardize the missing patient assessment to include 

elements from the VHA directive (2008-057). This action will 

standardize and serve as documentation for the missing patient 

assessment. 

• Outcome: A minimum of 5 chart reviews/month for a period of 

4 months will show 100% completion of the wandering/missing 

patient assessment. Monthly random record review for 4 months: 

N = number of completed documented assessments; D = number 

of assessments reviewed. Threshold = 100%. 

Target Completion Date: Complete/ongoing

Recommendation 2. We recommended that the VISN Director ensure 

that the Medical Center Director requires that data on resuscitation events 

and outcomes be discussed, analyzed, and compared over time to identify 

opportunities for improvement. 

VA Office of Inspector General 17 
 Combined Assessment Program Review of the Lexington VA Medical Center, Lexington, Kentucky 

Concur 

A recently hired surgical intensivist is now chairing the Critical Care 

Committee. In addition, we have added a new critical care nurse 

specialist who is responsible for maintaining the National Registry of 

CardioPulmonary Resuscitation (NRCPR) database and providing monthly 

reports to the Critical Care Committee. As of February 2009, this is a 

recurring monthly agenda item for the committee. The facility is also in the 

final stages of completely revamping its committee structure and charters 

to ensure appropriate functioning and oversight of all committee activities 

by a higher level Council, chaired by an accountable Quad member. 

Oversight of the Critical Care Committee is assigned to the Clinical 

Executive Council, chaired by the Chief of Staff. Findings, actions, and 

recommendations will also be reviewed and/or addressed by the Clinical 

Executive Council. 

Target Completion Date: Complete/ongoing

Recommendation 3. We recommended that the VISN Director ensure 

that the Medical Center Director requires that medical record reviews be 

completed in accordance with VHA policy and that deficiencies be 

addressed. 

Concur 

Although there were point of care reviews being done, results were not 

being consistently reported to the Medical Records Committee. The Chief 

of Health Information Management (HIMS) is developing a reporting 

matrix to summarize all ongoing point of care reviews; the responsible 

individuals; and the schedule for reporting results to the Medical Record 

Committee. A similar matrix is also being developed for other ongoing 

medical record reviews, including timeliness of progress note and orders 

signatures to ensure these are routinely reported to the Committee for 

discussion and development of further actions as needed. The matrices 

will be presented to the Medical Records Committee not later than March. 

These two areas are being added to the Medical Records Committee 

agenda template as monthly recurring report item. Findings, actions, and 

recommendations will also be reviewed and/or addressed by the Clinical 

Executive Council. 

Target Completion Date: March 31, 2009

Recommendation 4. We recommended that the VISN Director ensure 

that the Medical Center Director requires that provider PI data is collected, 

analyzed, and used to support decisions during the reprivileging process. 

Concur 

VA Office of Inspector General 18 
 Combined Assessment Program Review of the Lexington VA Medical Center, Lexington, Kentucky 

Key improvement actions were in progress at the time of the OIG visit 

including development of standardized provider-specific report cards using 

guidance from the VA Office of Quality and Performance and development 

of core privileges. These reports will be completed for all services by 

March 31, 2009, and will be consistently used for all re-privileging 

decisions after that date. Additional actions taken following the visit 

include revision of the Professional Standards Board minutes template to 

require comment on (1) plan for focused evaluation for new providers; 

(2) information considered in re-privileging recommendations (Ongoing 

Practice Evaluation Information). 

Target Completion Date: March 31, 2009

Recommendation 5. We recommended that the VISN Director ensure 

that the Medical Center Director requires that discharge instructions, 

discharge summaries, and physician orders be consistent. 

Concur 

Clinical pharmacists have oversight responsibility for inpatient medication 

reconciliation and are developing a standardized note template which 

includes key regulatory requirements and which will be printed and given 

to the patient prior to discharge. Medication lists will no longer be 

imported as data objects into discharge summaries or discharge nursing 

notes to ensure there is no inconsistent discharge medication information. 

These notes will instead reference the new medication reconciliation 

discharge note. Medical Records staff will monitor this and will report 

results to the Medical Record Committee. Findings, actions, and 

recommendations will also be reviewed and/or addressed by the Clinical 

Executive Council. 

Target Completion Date: March 31, 2009 

Recommendation 6. We recommended that the VISN Director ensure 

that the Medical Center Director requires that all inter-facility transfer 

documentation comply with VHA policy. 

Concur 

At the time of this finding, the Emergency Room (ER) director instituted an 

immediate process change, requiring the ER physician and nursing staff to

ensure there is a signed Interfacility Transfer form and consent for all 

patient transfers. The Administrative Officer of the Day (AOD) CPRS 

interfacility transfer note was also modified as a cross check to include 

validation that consent for transfer was available at the time of transfer. 

Health Administration Service (HAS) is monitoring transfer records to 

ensure that the required documentation is present and will provide 

immediate feedback of individual problems to the ER Director and 

VA Office of Inspector General 19 
 Combined Assessment Program Review of the Lexington VA Medical Center, Lexington, Kentucky 

Transfer Coordinator. In addition, aggregate data re: compliance with 

inter-facility transfer documentation requirements will be reported to the 

Medical Records Committee as point of care reviews starting in March. 

Findings, actions, and recommendations will also be reviewed and/or 

addressed by the Clinical Executive Council.

Target Completion Date: Complete/ongoing

Recommendation 7. We recommended that the VISN Director ensure 

that the Medical Center Director develops a system to assure that all ED 

nursing staff competencies are evaluated and documented annually. 

Concur 

The system for processing and filing nursing competencies has been 

changed so that in addition to copies being retained by responsible nurse 

managers, a copy of each RN proficiency is also being attached to the 

annual proficiency report and kept on file in the Official Personnel Files. 

Target Completion Date: Complete/ongoing 

Recommendation 8. We recommended that the VISN Director ensure 

that the Medical Center Director requires that nurses consistently 

document the effectiveness of all pain medications within the timeframe 

established by local policy. 

Concur 

Patient Care Services implemented an automated monitoring approach for 

PRN effectiveness documentation in November with drill down at the 

individual nurse level. Feedback is provided to unit managers and 

individual staff nurses on a weekly basis. Documentation of effectiveness 

is at 98% for the most recent report period. Monitoring timeliness of the 

documentation has been a greater challenge because of limitations in the 

BCMA package. The availability of accurate data has been limited by 

BCMA itself, and a remedy ticket and enhancement requests have been 

made to the national office so that the nurses can accurately document 

the time they actually assessed the prn effectiveness, not the time the 

data was entered into the computer. In the interim, extensive teaching 

has been done and will continue to be done with unit staff as well as 

individual users to show them how to enter information in a way that 

shows when they actually assessed the effectiveness of the prn 

medication. Monitoring of timeliness with feedback to managers and 

individual nurses will continue until the local measure of success threshold 

is met. Aggregate results will also be submitted as point of care reviews 

to the Medical Records Committee starting in March. Findings, actions, 

VA Office of Inspector General 20 
 Combined Assessment Program Review of the Lexington VA Medical Center, Lexington, Kentucky 

VA Office of Inspector General 21 

and recommendations will also be reviewed and/or addressed by the 

Clinical Executive Council. 

Target Completion Date: March 31, 2009 
Combined Assessment Program Review of the Lexington VA Medical Center, Lexington, Kentucky 

Appendix C 

VA Office of Inspector General 22 

OIG Contact and Staff Acknowledgments 

Contact Victoria Coates, Director 

Atlanta Office of Healthcare Inspections 

(404) 929-5961 

Contributors Nancy Albaladejo, Team Leader 

Audrey Collins-Mack 

Melanie Cool 

Tishanna McCutchen 

Susan Zarter 

Richard Ellison, Office of Investigations 
Combined Assessment Program Review of the Lexington VA Medical Center, Lexington, Kentucky 

Appendix D 

VA Office of Inspector General 23 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, Veterans Integrated Service Network (10N9) 

Director, Lexington VA Medical Center (596/00) 

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: Jim Bunning, Mitch McConnell 

U.S. House of Representatives: Ben Chandler

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