Department of Veterans Affairs

Office of Inspector General

Office of Healthcare Inspections

Report No. 08-02597-63

Combined Assessment Program 

Review of the 

VA Central Iowa Health Care System 

Des Moines, Iowa 

February 3, 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 VA Central Iowa Health Care System, Des Moines, Iowa 

Table of Contents 

Page 

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

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

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

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

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

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

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

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

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

Coordination of Care ......................................................................................... 9

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

Medication Management ................................................................................... 13

Emergency/Urgent Care Operations ................................................................. 14

Review Activities Without Recommendations ......................................................... 16

Staffing .............................................................................................................. 16

Survey of Healthcare Experiences of Patients .................................................. 16

Appendixes

A. VISN Director Comments .................................................................................. 19

B. System Director Comments............................................................................... 20

C. OIG Contact and Staff Acknowledgments ......................................................... 28

D. Report Distribution............................................................................................. 29

VA Office of Inspector General 
Combined Assessment Program Review of the VA Central Iowa Health Care System, Des Moines, Iowa 

Executive Summary 

Introduction During the week of October 27–31, 2008, the OIG conducted 

a Combined Assessment Program (CAP) review of the VA 

Central Iowa Health Care System (the system), Des Moines, 

IA. 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 88 system 

employees. The system is part of Veterans Integrated 

Service Network (VISN) 23. 

Results of the 

Review 

The CAP review covered eight operational activities. We 

identified the following organizational strengths and reported 

accomplishments: 

• Safety, efficiency, and patient satisfaction improved with 

the implementation of the telepharmacy program. 

• Performance improvement (PI) processes improved after 

initiation of the QM program redesign. 

We made recommendations in six of the activities reviewed 

and had repeat environment of care (EOC) findings from our 

prior CAP review. For these activities, the system needed to:

• Collect and consider provider-specific PI data during 

reprivileging, in accordance with Veterans Health 

Administration (VHA) policy. 

• Ensure that identified staff complete cardiopulmonary 

resuscitation (CPR) training, in accordance with system 

policy. 

• Establish a committee to provide oversight and 

coordination of the medical record review process. 

• Correct identified safety, infection control (IC), and patient 

privacy deficiencies. 

• Ensure that consultation responses are completed within 

the system’s established timeframe. 

• Ensure that transfer documentation is completed in 

accordance with system policy. 

• Ensure that discharge documentation accurately reflects 

active outpatient medications. 

• Complete monthly inspections of all areas where controlled 

substances (CS) are stored. 

VA Office of Inspector General i
Combined Assessment Program Review of the VA Central Iowa Health Care System, Des Moines, Iowa 

• Ensure that staff follow system policy regarding medication 

disposition upon admission. 

• Ensure that the Self-Medication Management Program 

(SMP) is implemented and managed in accordance with 

system policy. 

• Ensure that PRN (as needed) medication effectiveness is 

documented within the timeframe defined by system 

policy. 

• Ensure that patients discharged from the emergency 

department (ED) receive written discharge instructions. 

• Ensure that clinicians document inter-facility transfers in 

accordance with VHA policy. 

The system complied with selected standards in the following 

two activities: 

• Survey of Healthcare Experiences of Patients (SHEP). 

• Staffing. 

This report was prepared under the direction of 

Verena Briley-Hudson, Director, Chicago Office of 

Healthcare Inspections. 

Comments The VISN and System Directors concurred with the findings 

and recommendations and submitted acceptable 

improvement plans. (See Appendixes A and B, 

pages 19–27, 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 VA Central Iowa Health Care System, Des Moines, Iowa 

VA Office of Inspector General 1 

Introduction 

Profile The system is a two-division facility in Iowa that provides 

inpatient and outpatient health care services. It operates two 

inpatient divisions located in Des Moines and Knoxville. 

Outpatient care is provided at both divisions and at two 

community based outpatient clinics (CBOCs) in Mason City 

and Fort Dodge, IA. The system is part of VISN 23 

and serves a veteran population of more than 

100,000 throughout 42 counties in Iowa and 2 counties in 

northern Missouri. 

Programs. The system operates acute care, long-term 

care, and domiciliary beds. The Des Moines division 

provides primary care, medical, surgical, psychiatric, 

substance abuse, and home care services. The Knoxville 

division provides rehabilitation, mental health, and palliative 

community living center (CLC)1 care and is a referral center 

for acute and long-term mental health patients. The system 

has 77 hospital, 226 CLC, and 78 domiciliary beds. 

Affiliations. The system is affiliated with the University of 

Iowa’s Carver College of Medicine; the Des Moines Area 

Medical Education Consortium, Incorporated; and Des 

Moines University. The system provides training for 

25 residents, as well as other disciplines, including 

psychology, podiatry, physical therapy, nursing, and 

pharmacy. 

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

expenditures totaled $190.8 million. The FY 2009 medical 

care budget is approximately $200 million. FY 2008 staffing 

was 1,299 full-time employee equivalents (FTE), including 

50 physician and 230 nursing FTE. 

Workload. For FY 2008 through August 31, 2008, the 

system treated 32,098 unique patients. The system 

provided 12,914 inpatient days in the hospital and 

44,714 inpatient days in the CLC units. The inpatient care 

workload totaled 2,991 discharges, and the average daily 

census, including CLC patients, was 199. Outpatient 

workload totaled 299,077 visits. 

 

1

 CLC units (formerly called nursing home care units) provide compassionate, person-centered care in a safe and 

homelike environment to eligible veterans who require a nursing home level of care. 
Combined Assessment Program Review of the VA Central Iowa Health Care System, Des Moines, Iowa 

VA Office of Inspector General 2 

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 (E/UC) Operations.

• EOC.

• Medication Management.

• Pharmacy Operations.

• QM Program.

• SHEP.

• Staffing.

The review covered system operations for FY 2008 and 

FY 2009 through October 24, 2008, and was done in 

accordance with OIG standard operating procedures for CAP 

reviews. We also followed up on select recommendations 

from our prior CAP review of the system (Combined 

Assessment Program Review of the VA Central Iowa Health 

Care System, Des Moines, Iowa, Report No. 05-00839-156, 

June 24, 2005). We had two repeat EOC findings from our 

prior CAP review related to Veterans Canteen Service (VCS) 
Combined Assessment Program Review of the VA Central Iowa Health Care System, Des Moines, Iowa 

kitchen security and ceiling tiles in patient rooms and 

restrooms. 

During this review, we also presented fraud and integrity 

awareness briefings for 88 employees. These briefings 

covered procedures for reporting suspected criminal activity 

to the OIG and included case-specific examples illustrating 

procurement fraud, conflicts of interest, and bribery. 

In this report, we make recommendations for improvement. 

Recommendations pertain to issues that are significant 

enough to be monitored by the OIG until corrective actions 

are implemented. Activities in the “Review Activities Without 

Recommendations” section have no reportable findings.

Organizational Strengths 

Telepharmacy 

Program Improves 

Processes 

The telepharmacy program was developed to address issues 

that veterans at the CBOCs and the Knoxville division had 

with prior pharmacy processes. These issues often resulted 

in medication refill delays and limited patient education by 

pharmacists. 

The system installed an onsite automated drug dispensing 

system (ADDS) and a telehealth system to link the CBOCs 

and the Knoxville division with the main pharmacy at the 

Des Moines division. Full-time pharmacy technicians 

assigned to the CBOCs and the Knoxville division and a 

full-time pharmacist located at the Des Moines division 

communicate with veterans through video teleconferencing. 

The pharmacist controls medication dispensing through the 

ADDS. Telepharmacy program successes include: 

• Consistent patient education. 

• Efficiency in addressing pharmacy issues and 

reduced workload for non-pharmacy staff. 

• Medication reconciliation during each appointment 

and verification of each patient’s medication list. 

• Reduced cost per prescription with the use of ADDS 

technology. 

• Improved patient and staff satisfaction. 

VA Office of Inspector General 3 
Combined Assessment Program Review of the VA Central Iowa Health Care System, Des Moines, Iowa 

Quality 

Management 

Program Redesign 

Improves 

Efficiency 

To expand the culture of quality and increase focus on 

improvement at all levels, the approach to QM and PI was 

redesigned. The QM program was separated into two 

functions (1) traditional QM activities that support monitoring, 

oversight, and incremental improvement and (2) focused PI 

that supports major initiatives, collaboratives, and 

multi-disciplinary/multi-service PI activities. The QM program 

was expanded by hiring staff with expertise in facilitating PI 

teams and system redesign. In addition, three program 

analysts were added to support data management in both 

areas. These positions were in addition to the dedicated QM 

positions embedded in each of the four clinical service lines 

to manage data collection, support accreditation activities, 

and monitor VA clinical measures. 

The PI model was made more user-friendly by examining 

what to change, what to change to, how to change, and how 

to sustain. The model uses a variety of traditional PI tools 

but also focuses on how to ask critical questions and 

develop effective, sustainable solutions. A cadre of staff is 

being trained in PI and team facilitation, and training for staff 

in front line improvement is being developed. A SharePoint 

database will allow for documentation, communication, and 

tracking of actions and outcome data. Since implementation 

began in June 2008, access and performance scores have 

improved significantly, and various processes have been 

redesigned to improve efficiency and effectiveness. 

Results 

Review Activities With Recommendations 

Quality 

Management 

Program 

The purpose of this review was to evaluate whether the 

system had a comprehensive and effective QM program 

designed to monitor patient care activities and coordinate 

improvement efforts and whether senior managers actively 

supported the program’s activities. We interviewed the 

system’s Director, Chief of Staff, Chief of QM and PI, and we 

interviewed other key staff. We evaluated policies, PI data, 

and other relevant documents. 

The QM program was generally effective in providing 

oversight of the system’s quality of care, and senior 

managers supported the program through evaluation of PI 

initiatives and through allocation of resources to the 

program. Appropriate review structures were in place for 

VA Office of Inspector General 4 
Combined Assessment Program Review of the VA Central Iowa Health Care System, Des Moines, Iowa 

VA Office of Inspector General 5 

11 of the 14 program activities reviewed. We identified three 

areas that needed improvement. 

Physician Privileges. VHA policy2

 and accreditation 

standards require that clinical managers develop plans for 

continuous performance monitoring of the medical staff. 

Performance data collection should be ongoing and include 

indicators with defined criteria that emphasize the facility’s PI 

plan, appropriateness of care, patient safety, and desired 

outcomes. This data is to be reviewed and considered 

during the reprivileging process, which is to include an 

appraisal of professional performance, judgment, and 

clinical/technical competence of skills based in part on 

provider-specific PI activities. 

The system had recently developed and published a policy 

that specified the performance data that would be collected, 

compiled, and considered during the reprivileging process. 

However, the policy had not been fully implemented at the 

time of our visit. We reviewed the credentialing and 

privileging folders and provider files of 21 randomly selected 

physicians who had been initially privileged or reprivileged 

during the past 12 months and found that all had inadequate 

performance data. 

Cardiopulmonary Resuscitation Training. System policy 

requires CPR training for identified staff every 2 years. We 

reviewed the database used to track the training status of 

staff required to maintain current CPR training. Of the 

662 employee records reviewed, we found that 51 staff 

members were not in compliance with system policy at the 

time of our inspection. 

Medical Records Reviews. VHA policy3

 requires that 

medical records be reviewed on an ongoing basis at the 

point of care. Results of these record reviews are to be 

reported at least quarterly to the facility medical record 

review committee or its equivalent. We found that medical 

records reviews had been conducted on an ongoing basis; 

however, the system did not have a committee to provide 

oversight and coordination of these reviews. 

Recommendation 1 We recommended that the VISN Director ensure that the 

System Director requires that provider-specific PI data be 

 

2

 VHA Handbook 1100.19, Credentialing and Privileging, October 2, 2007. 3

 VHA Handbook 1907.01, Health Information Management and Health Records, August 25, 2006. 
Combined Assessment Program Review of the VA Central Iowa Health Care System, Des Moines, Iowa 

collected and considered during reprivileging, in accordance 

with VHA policy. 

The VISN and System Directors concurred with the findings 

and recommendation. Service line directors, QM staff, and 

employees from the Chief of Staff’s office will ensure that PI 

data is collected and considered during reprivileging. The 

improvement plan is acceptable, and we will follow up on the 

completion of the planned actions. 

Recommendation 2 We recommended that the VISN Director ensure that the 

System Director requires that employees complete CPR 

training, in accordance with system policy. 

The VISN and System Directors concurred with the finding 

and recommendation. Additional CPR training has been 

scheduled. The Education Service will monitor staff 

compliance and notify supervisors and managers of 

delinquencies. The improvement plan is acceptable, and we 

will follow up on the completion of the planned actions. 

Recommendation 3 We recommended that the VISN Director ensure that the 

System Director establishes a committee to provide 

oversight and coordination of the medical record review 

process. 

The VISN and System Directors concurred with the finding 

and recommendation. Senior managers have selected and 

appointed members to serve on a medical records oversight 

committee. The committee will meet at least once each 

quarter. The improvement plan is acceptable, and we will 

follow up on the completion of the planned actions. 

Environment of 

Care 

The purpose of this review was to determine if the system 

complied with selected IC standards and maintained a safe 

and clean patient care environment. VHA facilities are 

required to establish a comprehensive EOC program that 

fully meets VA National Center for Patient Safety, 

Occupational Safety and Health Administration, and 

accreditation standards. 

We inspected eight inpatient units (CLC, locked mental 

health, medical/surgical, telemetry, and intensive care), three 

outpatient clinics (red and blue teams and mental health), 

the VCS area, and several common areas. We also followed 

up on recommendations from our prior CAP review and 

noted that two conditions identified during that review still 

VA Office of Inspector General 6 
Combined Assessment Program Review of the VA Central Iowa Health Care System, Des Moines, Iowa 

existed (1) damaged, missing, incorrectly placed, or stained 

ceiling tiles were observed in patient rooms and restrooms 

and (2) an unlocked kitchen door was noted in the VCS area. 

We evaluated the IC program to determine compliance with 

VHA directives. IC staff appropriately collected, trended, and 

analyzed data related to infections, and they involved 

clinicians in improvement initiatives to reduce infection risks 

for patients and staff. 

The system was generally clean and effectively maintained. 

Managers and employees were responsive to environmental 

concerns identified during our inspection. However, we 

identified the following conditions that needed improvement. 

Safety. Medications, cleaning products, and sharp items 

must be secured when not in use. While conducting the 

inspection in the intensive care unit (ICU) at the Des Moines 

division, we found an unsecured respiratory saline solution, a 

liquid cleaning product stored underneath a sink, and 

unsecured syringes and scissors. 

Also, we found an improperly labeled medication in the ICU’s 

medication refrigerator. The manufacturer’s expiration date 

had been manually changed to another date. This change 

had not been authorized by a pharmacist. This practice is a 

potential patient safety risk. 

System policy requires licensed nursing personnel or other 

trained and competent staff to document the lock number on 

the crash cart and sign the Code Blue checklist each shift. 

We inspected the crash cart on CLC unit 101B at the 

Knoxville division and found that the lock number 

documented on the Code Blue checklist was inaccurate. 

Additionally, signatures were not consistently recorded on 

the Code Blue checklist for the month of October 2008. 

Staff were using a brick to hold the nursing clinic door open 

on unit 101A. Due to the patient population on this unit, this 

item needed to be removed to ensure patient and staff 

safety. 

Unsecured doors to VCS retail storage rooms at the 

Des Moines division allowed unauthorized access to food 

and merchandise. We also identified an unsecured kitchen 

door in the VCS area at the Knoxville division, which was a 

repeat finding from our prior CAP review. 

VA Office of Inspector General 7 
Combined Assessment Program Review of the VA Central Iowa Health Care System, Des Moines, Iowa 

Oxygen tanks must be stored so that staff may quickly 

identify which are full and which are empty. None of the 

units inspected at either division had a process to distinguish 

full and empty tanks. Additionally, there were no oxygen 

tanks available in the ICU in the event of an emergency. 

We observed two hospital beds with electric power cords in 

the hallway on the locked mental health unit at the Knoxville 

division. The unit does not utilize this type of bed due to the 

safety risk of the power cord. The storage of this equipment 

in the hallway posed an immediate safety concern. 

Staff must be prepared to provide quick responses to 

emergency call systems. We activated the emergency call 

system in the restraint room on the locked mental health unit. 

Although staff on the unit heard the alarm, there was a 

delayed response. 

Infection Control. Ceiling tiles must be intact and in proper 

placement to minimize the potential for pest or particulate 

entry. Ceiling tile problems were noted in patient rooms and 

restrooms at both the Des Moines and Knoxville division. 

This was a repeat finding from our prior CAP review. 

Additionally, during our inspection of the room where the 

ADDS is located at the Knoxville division (Building 1, 

Room 138), we observed that a ceiling tile had been 

removed for repairs but had not been replaced even though 

it appeared that the work had been completed. We also 

noted that several of the ceiling tiles were cut or damaged or 

had penetrations that had not been properly sealed. 

Refrigerators must be monitored daily to ensure that 

contents are safe. Nourishment refrigerator temperature 

logs on two inpatient units showed that the refrigerators were 

out of the acceptable range on select dates. Staff did not 

document corrective actions in the logs. 

Patient care areas should be inspected for pests, and 

actions should be initiated immediately when problems are 

identified. We observed insects in the dining room on unit 

101B and in patient areas on units 101C and 68D at the 

Knoxville division. Staff had not initiated any requests for 

pest control services. 

Clean and dirty items were stored together in storage rooms 

at both divisions. Also, biohazardous trash receptacles in 

the primary care clinic at the Des Moines division and the 

VA Office of Inspector General 8 
Combined Assessment Program Review of the VA Central Iowa Health Care System, Des Moines, Iowa 

locked mental health unit at the Knoxville division were not 

adequately secured to restrict access. 

Patient care equipment needs to be regularly inspected, and 

items with compromised surfaces need to be repaired or 

removed from service. We observed wheelchairs with 

cracked armrests and seat surfaces at the Knoxville division. 

Patient Privacy. Federal law requires the protection of 

sensitive patient information. Documents with patients’ 

names, social security numbers, dates of birth, and health 

information were attached to clipboards hanging on the walls 

inside patient rooms on the medical/surgical unit at the 

Des Moines division. Managers require staff to use plastic 

covers over these sensitive documents. We noted that 

plastic covers were in place in only two of eight patient 

rooms inspected on this unit. 

We witnessed nurses logging into the Bar Code Medication 

Administration (BCMA) software package on portable laptop 

computers in patient care areas. The nurses would then 

leave the laptop computers in the hallway while they entered 

patient rooms with a portable BCMA scanning device to scan 

patient armbands. After scanning an armband, the patient’s 

name, date of birth, allergies, and medication profile 

appeared on the laptop screen. Because the laptops were 

left in the hallway, there was the potential for unauthorized 

individuals to view the sensitive patient information on the 

screens. 

Recommendation 4 We recommended that the VISN Director ensure that the 

System Director requires that identified safety, IC, and 

patient privacy deficiencies be corrected. 

The VISN and System Directors concurred with the findings 

and recommendation. The system developed appropriate 

plans to address each EOC deficiency identified during the 

inspection. The improvement plans are acceptable, and we 

will follow up on the completion of the planned actions. 

Coordination of 

Care 

The purpose of this review was to evaluate whether inpatient 

consultations, transfers, and discharges were appropriately 

coordinated and met VHA and accreditation standards. 

Coordinated consultations, transfers, and discharges are 

essential to an integrated, ongoing care process resulting in 

VA Office of Inspector General 9 
Combined Assessment Program Review of the VA Central Iowa Health Care System, Des Moines, Iowa 

VA Office of Inspector General 10 

optimal patient outcomes. We identified three areas that 

needed improvement. 

Consultations. System policy requires that inpatient consults 

be seen by the specialty/subspecialty service and that a 

consult-titled progress note be signed and available to the 

requesting party preferably within 24 hours but no longer 

than within 72 hours of the request. We reviewed the 

medical records of 12 inpatients who had routine 

consultations ordered and completed internally. Four 

(33 percent) of the 12 consultations did not meet this 

timeframe. 

Intra-Facility Transfers. System policy requires that progress 

note assessments be completed by registered nurses (RNs) 

from the sending and receiving units when patients are 

transferred. We reviewed the medical records of 12 patients 

who transferred between units. Four transfer notes were 

initiated by licensed practical nurses (LPNs) on the sending 

units with RN “receipt acknowledged by” signatures. Senior 

managers clarified that this was not meeting the intent of 

system policy and that RNs should have initiated the notes. 

Additionally, we identified that there was no transfer note 

initiated by the sending unit for one patient in our sample 

who transferred between units at the Knoxville division. 

Discharges. VHA policy4 addresses information to be 

documented in the medical record when a patient is 

discharged from the facility. We reviewed the medical 

records of 12 inpatients who were discharged from the 

system. We identified two instances in which provider 

discharge notes included outpatient medications that were 

listed twice. If this information is given to the patient, there is 

the potential for errors in medication dosing. We also 

identified two discrepancies in discharge documentation. In 

the first instance, the provider’s orders and the pharmacy 

discharge instructions note included two medications that 

were not included in the provider’s discharge note. In the 

second instance, the provider’s discharge summary did not 

include medications that were listed in the provider’s 

discharge note or in the pharmacy discharge instructions 

note. 

 

4

 VHA Handbook 1907.01. 
Combined Assessment Program Review of the VA Central Iowa Health Care System, Des Moines, Iowa 

Recommendation 5 We recommended that the VISN Director ensure that the 

System Director requires that consultation responses be 

completed within the system’s established timeframe. 

The VISN and System Directors concurred with the finding 

and recommendation. Each service line will appoint at least 

one back-up person to ensure that inpatient consultation 

requests are received, patients are seen, and responses are 

documented within the established timeframe. The 

improvement plan is acceptable, and we will follow up on the 

completion of the planned actions. 

Recommendation 6 We recommended that the VISN Director ensure that the 

System Director requires that transfer documentation be 

completed in accordance with system policy. 

The VISN and System Directors concurred with the findings 

and recommendation. Nursing staff were educated on 

transfer documentation requirements, and LPNs no longer 

initiate transfer notes. QM and Health Information 

Management Service staff will continue to monitor transfer 

documentation to ensure sustained compliance. The 

improvement plan is acceptable, and we will follow up on the 

completion of the planned actions. 

Recommendation 7 We recommended that the VISN Director ensure that the 

System Director requires that discharge documentation 

accurately reflects active outpatient medications. 

The VISN and System Directors concurred with the findings 

and recommendation. Importing of medication lists into 

provider discharge instructions or other discharge 

documents is being discontinued. A process is under 

development to address entry of discharge medication 

orders, reconciliation of discharge medications, printing of a 

single list of medications for patients to take home, and 

completion of medication education. The improvement plan 

is acceptable, and we will follow up on the completion of the 

planned actions. 

Pharmacy 

Operations 

The purpose of this review was to evaluate whether the 

system had adequate controls to ensure the security and 

proper management of CS and the pharmacy’s internal 

physical environment. We also assessed whether processes 

were in place to monitor polypharmacy (patients prescribed 

multiple medications), especially in vulnerable populations. 

VA Office of Inspector General 11 
Combined Assessment Program Review of the VA Central Iowa Health Care System, Des Moines, Iowa 

We reviewed VHA regulations governing pharmacy and CS 

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

practices were consistent with VHA regulations. We 

inspected the Des Moines division pharmacy and Knoxville 

division areas where medications and CS were stored for 

security, EOC, and IC issues. Additionally, we interviewed 

the CS Coordinator, the pharmacy manager, pharmacy 

employees, and the Chief of Police. 

Pharmacological regimens involving multiple medications are 

often necessary to prevent and maintain disease states; 

however, excessive use of medications can result in adverse 

reactions and increased risks of complications. 

Polypharmacy is more complex than just the number of 

drugs that patients are prescribed. The clinical criteria to 

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

have no apparent indication, (b) therapeutic equivalents to 

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

prescribed drugs, (d) inappropriate medication dosages, and 

(e) medications to treat adverse drug reactions. Elderly and 

mental health patients are among the most vulnerable 

populations for polypharmacy. 

Managers had developed effective processes to ensure that 

clinical pharmacists identified patients who were prescribed 

multiple medications, reviewed their medication regimens to 

avoid polypharmacy, and advised providers as appropriate. 

Policies and procedures were in place to ensure the security 

of the pharmacy and CS. The CS Coordinator and CS 

inspectors were appointed in writing by the system’s Director 

and received the required training to perform their duties. 

The pharmacy’s internal environment was clean and well 

maintained. We identified one area that needed 

improvement. 

Controlled Substances Inspections. Monthly, random 

inspections are required to be conducted in all areas where 

CS are stored. Through interviews and reviews of inspection 

documents, we learned that the September 2008 inspection 

of the Des Moines domiciliary was missed. 

Recommendation 8 We recommended that the VISN Director ensure that the 

System Director requires that monthly inspections be 

completed of all areas where CS are stored. 

VA Office of Inspector General 12 
Combined Assessment Program Review of the VA Central Iowa Health Care System, Des Moines, Iowa 

The VISN and System Directors concurred with the finding 

and recommendation. The CS Coordinator provided 

education for current and newly appointed inspectors and 

will monitor monthly inspections to ensure that all are 

completed. The improvement plan is acceptable, and we will 

follow up on the completion of the planned actions. 

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 

medication management processes on an acute medicine 

unit, the ICU, and three CLC units. We found appropriate 

use of patient armbands to correctly identify patients prior to 

medication administration. We identified three areas that 

needed improvement. 

Medication Disposition Upon Admission. System policy 

requires that medications brought from home be returned to 

family members or placed in a sealed mailing envelope to be 

mailed to the patient’s residence. During our inspection of 

one of the CLC units, we found outpatient medications 

stored on the unit for two patients. 

Self-Medication Management Program. System policy 

requires that a progress note and a provider’s order be 

documented prior to a patient’s entry into the SMP. This 

documentation should include an assessment of the patient’s 

degree of knowledge and understanding of the name of each 

medication, the administration of each medication, storage 

requirements, reasons for taking each medication, common 

side effects, integration of medications into the patient’s 

lifestyle, possible barriers to compliance, possible barriers to 

learning, and procedures for requesting a change in 

medication. Additionally, based upon the results of the 

assessment, each patient must be categorized as either a 

semi-independent (levels I-IV) or an independent participant 

in the SMP. We reviewed the records of three patients 

identified as currently participating in the SMP. None of 

these records contained the initial documentation required or 

a categorized level of participation. 

Medication Effectiveness Documentation. System policy 

requires that the effectiveness of PRN medications be 

documented in the patient’s medical record within 4 hours of 

administration. We reviewed PRN effectiveness 

documentation for 67 doses of pain medications and found 

VA Office of Inspector General 13 
Combined Assessment Program Review of the VA Central Iowa Health Care System, Des Moines, Iowa 

that only 34 (51 percent) were documented within the 

timeframe defined by policy. 

Recommendation 9 We recommended that the VISN Director ensure that the 

System Director requires that staff follow system policy 

regarding medication disposition upon admission. 

The VISN and System Directors concurred with the finding 

and recommendation. Nursing staff were educated 

regarding the need for personal patient medications to be 

sent home with family members or sent to the pharmacy for 

destruction. Weekly monitoring will be initiated to ensure 

sustained compliance. The improvement plan is acceptable, 

and we will follow up on the completion of the planned 

actions. 

Recommendation 10 We recommended that the VISN Director ensure that the 

System Director takes action to ensure that the SMP is 

implemented and managed in accordance with system 

policy. 

The VISN and System Directors concurred with the findings 

and recommendation. The Mental Health Service Line will 

develop a template for documentation and will provide staff 

education on SMP requirements. The improvement plan is 

acceptable, and we will follow up on the completion of the 

planned actions. 

Recommendation 11 We recommended that the VISN Director ensure that the 

System Director takes action to ensure that PRN medication 

effectiveness is documented within the timeframe defined by 

system policy. 

The VISN and System Directors concurred with the finding 

and recommendation. Acute care and CLC nursing staff will 

receive education regarding documentation of PRN 

effectiveness. Daily audits are planned to monitor for 

sustained compliance. The improvement plan is acceptable, 

and we will follow up on the completion of the planned 

actions. 

Emergency/Urgent 

Care Operations 

The purpose of this review was to evaluate whether the 

system’s E/UC operations complied with VHA guidelines 

related to hours of operation, clinical capability, staffing 

adequacy, and staff competency. In addition, we inspected 

the system’s ED environment for cleanliness and safety. 

VA Office of Inspector General 14 
Combined Assessment Program Review of the VA Central Iowa Health Care System, Des Moines, Iowa 

VA Office of Inspector General 15 

The system’s ED is open 24 hours per day, 7 days per week, 

as required. It is located within the main hospital building at 

the Des Moines division, and the emergency services 

provided are within the system’s capability. In addition, there 

is an appropriate policy for managing patients whose care 

may exceed the facility’s capability. We identified two areas 

that needed improvement. 

Patient Discharge Instructions. Accreditation standards 

require that written discharge instructions be provided in a 

form that the patient can understand. We reviewed the 

medical records of two patients treated and discharged from 

the ED. We did not find documentation of discharge 

instructions for either patient. 

Inter-Facility Transfer Documentation. VHA policy5 requires 

the use of specific forms for the documentation of 

inter-facility transfers. We reviewed the medical records of 

three patients who were initially treated in the ED and then 

transferred to other facilities. Clinicians did not utilize the 

required VA transfer forms. Consequently, documentation 

such as informed consent, advance directives, and level of 

care required during transportation was omitted. 

Recommendation 12 We recommended that the VISN Director ensure that the 

System Director requires that patients discharged from the 

ED receive written discharge instructions. 

The VISN and System Directors concurred with the finding 

and recommendation. An emergency department discharge 

instructions template will be developed, and standardized 

patient education materials will be compiled. Staff will be 

educated on the process. The improvement plan is 

acceptable, and we will follow up on the completion of the 

planned actions. 

Recommendation 13 We recommended that the VISN Director ensure that the 

System Director requires that clinicians document 

inter-facility transfers in accordance with VHA policy. 

The VISN and System Directors concurred with the findings 

and recommendation. The transfer policy is being updated, 

and managers will ensure that all required transfer 

documentation is completed. The improvement plan is 

 

5

 VHA Directive 2007-015, Inter-Facility Transfer Policy, May 7, 2007. 
Combined Assessment Program Review of the VA Central Iowa Health Care System, Des Moines, Iowa 

acceptable, and we will follow up on the completion of the 

planned actions. 

Review Activities Without Recommendations 

Staffing The purpose of this review was to evaluate whether the 

system had developed comprehensive nurse staffing 

guidelines and to determine if the nurse staffing provided 

corresponded to the system’s methodology. Identifying and 

providing the correct number and/or mix of nurses is 

essential to the delivery of high quality patient care. 

The system’s staffing methodology is based upon a mix of 

licensed and non-licensed personnel varied by night, day, 

and evening shifts. We reviewed staffing for five inpatient 

units for three randomly selected dates. The dates included 

a week day, a weekend day, and a holiday. We reviewed 

nurse staffing documents and interviewed managers for 

select units (including CLC, acute psychiatry, and general 

medicine/surgery). We found the nurse staffing methodology 

to be appropriate. We made no recommendations. 

Survey of 

Healthcare 

Experiences of 

Patients 

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

system uses quarterly SHEP results to improve patient care, 

treatment, and services. The Performance Analysis Center 

for Excellence of the Office of Quality and Performance 

within VHA is the analytical, methodological, and reporting 

staff for SHEP. VHA set performance measure results for 

patients reporting overall satisfaction of “very good” or 

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

outpatients. 

Figures 1 and 2 on the next page show the system’s SHEP 

performance measure results for inpatients and outpatients, 

respectively. 

VA Office of Inspector General 16 
Combined Assessment Program Review of the VA Central Iowa Health Care System, Des Moines, Iowa 

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

VA CENTRAL IOWA HEALTH CARE SYSTEM

INPATIENT OVERALL QUALITY

BY QUARTER

Meets 

Target

Figure 1:

60

65

70

75

80

85

90

95

100

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

Quarter Reported

Percent Reporting Overall Quality as Very Good or Excellent

Facility

VISN

National

VA CENTRAL IOWA HEALTH CARE SYSTEM

OUTPATIENT OVERALL QUALITY

BY QUARTER

Figure 2:

Meets 

Target

We reviewed survey results for quarter 4 of FY 2006 through 

quarter 3 of FY 2008. The system’s inpatient results 

VA Office of Inspector General 17 
Combined Assessment Program Review of the VA Central Iowa Health Care System, Des Moines, Iowa 

VA Office of Inspector General 18 

exceeded the target in all 8 quarters reviewed. The system’s 

outpatient results exceeded the target in 7 of 8 quarters 

reviewed. Managers had analyzed survey results, identified 

opportunities for improvement, initiated an action plan, and 

evaluated the plan for effectiveness. We made no 

recommendations. 
Combined Assessment Program Review of the VA Central Iowa Health Care System, Des Moines, Iowa 

Appendix A 

VISN Director Comments 

VA Office of Inspector General 19 

Department of 

Veterans Affairs Memorandum 

Date: December 17, 2008 

From: Director, VA Midwest Health Care Network (10N23) 

Subject: Combined Assessment Program Review of the VA 

Central Iowa Health Care System, Des Moines, Iowa 

To: Director, Chicago Office of Healthcare Inspections (54CH) 

Director, Management Review Service (10B5) 

Thank you for the opportunity to review and provide comments. 

 (original signed by:) 

ROBERT A. PETZEL, M.D. 
Combined Assessment Program Review of the VA Central Iowa Health Care System, Des Moines, Iowa 

Appendix B 

System Director Comments 

VA Office of Inspector General 20 

Department of 

Veterans Affairs Memorandum 

Date: December 17, 2008 

From: Director, VA Central Iowa Health Care System (636A6/00) 

Subject: Combined Assessment Program Review of the VA 

Central Iowa Health Care System, Des Moines, Iowa 

To: Director, VA Midwest Health Care Network (10N23) 

Director, Chicago Office of Healthcare Inspections (54CH) 

Our responses to the OIG recommendations are included in this report. 

We appreciated the opportunity to have our programs reviewed in order to 

continuously improve our processes. 

 (original signed by:) 

DONALD C. COOPER 
Combined Assessment Program Review of the VA Central Iowa Health Care System, Des Moines, Iowa 

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 provider-specific PI data be 

collected and considered during reprivileging, in accordance with VHA 

policy. 

Concur Target Date of Completion: March 1, 2009 

Audit of the practitioner database revealed the required data was present 

for those practitioners re-privileged from July 2008 to the present. Service 

Line Directors, Quality Management, and Chief of Staff’s Office will assure 

implementation for all practitioners in accordance with policy. 

Recommendation 2. We recommended that the VISN Director ensure 

that the System Director requires that employees complete CPR training, 

in accordance with system policy. 

Concur Target Date of Completion: January 16, 2009 

Review of CPR training database revealed staff that had been included 

inappropriately; database is being updated to ensure alignment with policy 

and monitored quarterly by Education Service. Additional CPR training 

opportunities have been scheduled. Education Service will actively 

monitor staff compliance with training and notify supervisors/managers of 

delinquencies; managers will initiate corrective action with delinquent staff 

as indicated. 

Recommendation 3. We recommended that the VISN Director ensure 

that the System Director establishes a committee to provide oversight and 

coordination of the medical record review process. 

Concur Target Date of Completion: February 15, 2009 

A draft charter to establish a medical records oversight committee has 

been drafted and membership selection and appointment initiated on 

December 2, 2008. Committee will meet at least quarterly to monitor 

clinical record review findings and initiate improvements. 

VA Office of Inspector General 21 
Combined Assessment Program Review of the VA Central Iowa Health Care System, Des Moines, Iowa 

Recommendation 4. We recommended that the VISN Director ensure 

that the System Director requires that identified safety, IC, and patient 

privacy deficiencies be corrected. 

Concur Completed 

Ceiling tiles. Work orders were initiated and completed by 

November 14, 2008, for all ceiling tile repair/replacement in areas 

identified. All occupied areas at all sites are inspected twice per year 

through the EOC Rounds inspection process, and inspection tool is 

utilized which specifically identifies damaged/stained ceiling tiles as a 

point of inspection. To improve monitoring and maintenance, two 

“customer service” positions have been developed and approved for the 

Engineering Service, with the primary responsibility for daily/frequent 

rounds on all inpatient and outpatient care areas, where they will work with 

clinical supervisors to either correct the EOC/facility issues “on the spot” or 

initiate work requests for correction. 

Concur Target Date of Completion: February 1, 2009 

Unlocked kitchen door in the VCS area. A work order has been initiated to 

have a panic alarm bar installed that will assure the door is closed and 

locked at all times while maintaining fire safety standards for egress. 

Identified Safety Issues: 

Concur Target Date of Completion: February 1, 2009 

Medications, cleaning products, and sharp items security. Immediate 

action was taken onsite to correct the identified deficiencies. Nursing and 

Respiratory Therapy (RT) staff were re-instructed regarding required 

storage/securing of items. A process has been established to monitor for 

inappropriate unsecured items on each unit during daily rounds. 

Concur Completed 

Lock number on the crash cart and signatures on the Code Blue checklist. 

Immediate action was taken to change the lock out tag on 

October 28, 2008, and SPD employees were instructed to document tag 

changes and dates on the crash cart check sheet. RNs were re-educated 

regarding crash cart checks and documentation on October 31, 2008. A 

process has been established to monitor for appropriate checks and 

signatures, and Nurse Managers will follow up with appropriate corrective 

action with staff for missing signatures. 

Concur Target Date of Completion: February 1, 2009 

VA Office of Inspector General 22 
Combined Assessment Program Review of the VA Central Iowa Health Care System, Des Moines, Iowa 

Brick holding nursing clinic door open. Action was taken to remedy the 

immediate situation, and a work order was initiated to have the door 

repaired. 

Concur Completed 

Unsecured doors to the VCS retail storage rooms at the Des Moines 

division. Staff have been instructed regarding the requirement for 

storeroom doors within the retail store to remain closed at all times except 

while in the process of stocking shelves or pop coolers. 

Concur Target Date of Completion: February 1, 2009 

Oxygen tanks labeled full/empty; emergency tanks available in the ICU. 

Immediate action was taken to obtain replacement tanks in the ICU. SPD 

will establish a process for monitoring and replacement of empty oxygen 

tanks on the clinical units; labeling full/empty tanks has been implemented 

in all areas where oxygen is available. ICU and RT staff to notify SPD of 

need for additional tanks. 

Concur Completed 

Hospital beds on the locked mental health unit. Immediate action was 

taken to remove the beds from the unit, and staff were re-educated on the 

proper storage of equipment. 

Concur Target Date of Completion: February 1, 2009 

Delayed response to emergency call alarm. Staff have been re-instructed 

regarding the need for rapid response to emergency call system. A 

monitor has been established to evaluate staff response to emergency call 

system and provide feedback to staff. 

Identified Infection Control Issues: 

Concur Target Date of Completion: February 1, 2009 

Nutrition refrigerator monitoring. Food Service supervisors are re-training 

Nutrition and Food Service staff regarding monitoring and initiating 

corrective action when refrigerator temperatures go out of range. 

Checkpoint temperature monitoring system to be reevaluated to address 

frequent inaccuracies. 

Concur Completed 

Pest inspections. Immediate action was taken to address the identified 

deficiency. Inspection for pests has been added to the checklist for 

Housekeeping assigned areas. Pest sightings will be immediately 

VA Office of Inspector General 23 
Combined Assessment Program Review of the VA Central Iowa Health Care System, Des Moines, Iowa 

reported to the Environmental Management Service (EMS) coordinator. 

Pest vendor will be notified and will be required to remedy the problem 

within 4 hours of the sighting. 

Concur Target Date of Completion: February 1, 2009 

Storage rooms and trash. Trash receptacles were immediately removed 

to appropriate spaces. All nursing staff and RTs will be educated on the 

proper usage of clean storage rooms and separation of clean/dirty. 

Monitoring of storage areas has been added to Nurse Manager unit 

rounds. EMS staff will monitor and report deficiencies in storage areas. 

Concur Target Date of Completion: March 1, 2009 

Wheelchairs. The processes for inspecting, identifying, and implementing 

wheelchair and other equipment cleaning and repair requests will 

reviewed and updated to attain consistency across campuses. Monitoring 

of equipment state of repair and cleanliness will be added to 

Environmental/Infection Control rounds. 

Identified Patient Privacy Issues: 

Concur Target Date of Completion: March 1, 2009 

Bedside clinical information uncovered. Plastic covers were placed on all 

bedside clipboards. Managers have added monitoring for appropriate 

privacy covers on the clipboards to Nurse Manager unit rounds. 

Concur Target Date of Completion: March 1, 2009 

BCMA laptop computers unattended when sensitive information loads and 

displays. Nursing staff will be re-educated regarding the BCMA process to 

take the BCMA cart into the patient’s room, if space permits, while giving 

medications. If unable to take into the room because of space or infection 

control issues, nurse is to lower screen or log off. Process for daily 

reminders to all nursing staff to be initiated on January 15, 2009. Privacy 

screens will be explored for BCMA laptops. 

Recommendation 5. We recommended that the VISN Director ensure 

that the System Director requires that consultation responses be 

completed within the system’s established timeframe. 

Concur Target Date of Completion: March 1, 2009 

Each Service Line will appoint one or more back-up persons to receive all 

inpatient consults in addition to consulting providers; the back-up 

person(s) will follow-up to ensure patient is seen and documentation is 

completed within established timeframes. Chief of Staff’s Office and 

VA Office of Inspector General 24 
Combined Assessment Program Review of the VA Central Iowa Health Care System, Des Moines, Iowa 

Systems Redesign Coordinator will work with Service Line Directors to 

develop a consistent sustainable process to ensure all inpatient consults 

are seen and documentation is completed within established timeframes. 

Recommendation 6. We recommended that the VISN Director ensure 

that the System Director requires that transfer documentation be 

completed in accordance with system policy. 

Concur Target Date of Completion: March 1, 2009 

Nursing staff re-instructed regarding the requirement for RN 

documentation of transfers and appropriate completion of transfer notes. 

The practice of LPNs completing the transfer note was stopped. 

QM/Health Information Management Service will monitor medical-surgical 

and mental health transfer documentation to assure sustained 

compliance. 

Recommendation 7. We recommended that the VISN Director ensure 

that the System Director requires that discharge documentation accurately 

reflects active outpatient medications. 

Concur Target Date of Completion: February 1, 2009 

Importing of medication lists into the provider’s discharge instructions or 

other discharge documents is being stopped. A process is being 

developed that addresses entry of discharge medication orders, 

reconciliation of discharge medications, printing of a single list of 

medications the patient is to take at home, and completion of medication 

education. 

Recommendation 8. We recommended that the VISN Director ensure 

that the System Director requires that monthly inspections be completed 

of all areas where CS are stored. 

Concur Completed 

CS Coordinator completed additional education of both current and newly 

appointed inspectors regarding the requirement for inspections to be 

performed in their assigned calendar month. In the event an inspector 

cannot complete the assigned inspection by month’s end, the CS 

Coordinator is to be contacted immediately and an alternate is assigned to 

complete the inspection. CS Coordinator will monitor monthly inspections 

completed/not completed prior to the end of the month to assure timely 

inspection. CS Coordinator has enhanced the yearly inspector 

evaluations to include a self-assessment on subject knowledge. 

VA Office of Inspector General 25 
Combined Assessment Program Review of the VA Central Iowa Health Care System, Des Moines, Iowa 

Recommendation 9. We recommended that the VISN Director ensure 

that the System Director requires that staff follow system policy regarding 

medication disposition upon admission. 

Concur Completed 

The finding was immediately corrected onsite. Nursing staff were 

re-instructed on November 15, 2008, regarding the need to have the 

patient’s personal medications given to family members or sent to 

pharmacy to be destroyed. A process for weekly random inspections to 

ensure medications are not stored on the unit is being implemented. 

Recommendation 10. We recommended that the VISN Director ensure 

that the System Director takes action to ensure that the SMP is 

implemented and managed in accordance with system policy. 

Concur Target Date of Completion: February 1, 2009 

Mental Health Service Line will develop an educational handout to explain 

the security requirements to patients and a template for documentation of 

the required medication education per SMP policy. Staff training 

regarding educational requirements and the new medication education 

template will be completed by management. Practitioners will order level 

of medication administration needed by a veteran as Level I-IV and 

independent medication administration on admit and as needed through 

treatment. Compliance with all aspects of the process will be monitored 

for sustained improvement 

Recommendation 11. We recommended that the VISN Director ensure 

that the System Director takes action to ensure that PRN medication 

effectiveness is documented within the timeframe defined by system 

policy. 

Concur Target Date of Completion: January 1, 2009 

Acute and CLC nursing staff are being re-educated in unit meetings and 

by e-mail regarding the requirement for documentation of PRN 

effectiveness. A process for daily audit of compliance with PRN 

medication documentation has been developed, and Nurse Managers will 

provide timely feedback and take appropriate steps to assist individual 

staff with compliance. 

Recommendation 12. We recommended that the VISN Director ensure 

that the System Director requires that patients discharged from the ED 

receive written discharge instructions. 

Concur Target Date of Completion: February 1, 2009 

VA Office of Inspector General 26 
Combined Assessment Program Review of the VA Central Iowa Health Care System, Des Moines, Iowa 

VA Office of Inspector General 27 

Emergency Department (ED) staff and Quality Manager will develop an 

ED discharge instruction template that addresses those elements 

appropriate to ED patients and compile standardized educational 

materials to be available on the unit for dissemination to patients. Staff 

will be educated and the process implemented by February 1, 2009. Use 

of the new instruction form will be monitored by QM. The national ED 

instruction template currently under development will be implemented 

when published. 

Recommendation 13. We recommended that the VISN Director ensure 

that the System Director requires that clinicians document inter-facility 

transfers in accordance with VHA policy. 

Concur Target Date of Completion: February 1, 2009 

Transfer policy is currently being updated. ED Nurse Manager will replace 

current Inter-Agency Transfer form with the appropriate form per VHA 

Directive 2007-015. ED Nurse Manager will assess the use of i-Med 

consent, paper forms, scanning and/or template documentation for the 

most useful method to document transfers. 
Combined Assessment Program Review of the VA Central Iowa Health Care System, Des Moines, Iowa 

Appendix C 

VA Office of Inspector General 28 

OIG Contact and Staff Acknowledgments 

Contact Verena Briley-Hudson, RN, MN, Director 

Chicago Office of Healthcare Inspections 

(708) 202-2672 

Contributors Jennifer Reed, RN, Team Leader 

Lisa Barnes, MSW 

Judy Brown 

Paula Chapman, CTRS 

Roberta Thompson, MSW 

James Werner, Office of Investigations 
Combined Assessment Program Review of the VA Central Iowa Health Care System, Des Moines, Iowa 

Appendix D 

VA Office of Inspector General 29 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VA Midwest Health Care Network (10N23) 

Director, VA Central Iowa Health Care System (636A6/00) 

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: Christopher S. Bond, Chuck Grassley, Tom Harkin, Claire McCaskill 

U.S. House of Representatives: Leonard L. Boswell, Sam Graves, Steve King, 

Tom Latham 

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