Department of Veterans Affairs

Office of Inspector General

Office of Healthcare Inspections

Report No. 08-00400-190

Combined Assessment Program 

Review of the 

St. Louis VA Medical Center 

St. Louis, Missouri 

August 26, 2008

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 St. Louis VA Medical Center, St. Louis, Missouri 

Table of Contents 

Page 

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

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

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

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

Organizational Strength............................................................................................. 3

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

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

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

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

Pharmacy Operations........................................................................................ 13

Follow-Up on Background Investigations and Security Clearances................... 15

Follow-Up on Moderate Sedation Practices ...................................................... 16

Review Activities Without Recommendations ......................................................... 18

Survey of Healthcare Experiences of Patients .................................................. 18

Appendixes

A. VISN Director Comments .................................................................................. 21

B. Medical Center Director Comments................................................................... 22

C. OIG Contact and Staff Acknowledgments ......................................................... 33

D. Report Distribution............................................................................................. 34

VA Office of Inspector General 
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri 

Executive Summary 

Introduction During the week of May 5–9, 2008, the OIG conducted a 

Combined Assessment Program (CAP) review of the 

St. Louis VA Medical Center (the medical center), St. Louis, 

MO. 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 

269 medical center employees. The medical center is part of 

Veterans Integrated Service Network (VISN) 15. 

Results of the 

Review 

The CAP review covered six operational activities. We 

identified the following organizational strength and reported 

accomplishment: 

• Diversity Award Recipient. 

We made recommendations in five of the activities reviewed. 

Five recommendations were repeat recommendations from 

our two most recent CAP reviews. For these activities, the 

medical center needed to: 

• Ensure that performance data is used in the credentialing 

and privileging (C&P) process, in accordance with 

Veterans Health Administration (VHA) policy. 

• Meet VHA requirements for cardiopulmonary resuscitation 

(CPR) training for all clinically active staff. 

• Ensure that contracted providers are not privileged beyond 

their association with the medical center. 

• Meet VHA timeliness requirements for peer reviews (PRs). 

• Meet VHA requirements for inter-rater reliability (IRR) 

reviews for the utilization management (UM) program. 

• Meet VHA requirements for copying and pasting text into 

the electronic medical record. 

• Require that moderate sedation data be critically analyzed, 

trended, and monitored. 

• Complete operative reports in accordance with VHA policy. 

• Ensure that processes are in place to address patient flow 

in temporary bed and overflow locations. 

• Correct infection control (IC) vulnerabilities. 

• Correct safety vulnerabilities. 

VA Office of Inspector General i
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri 

• Correct patient privacy vulnerabilities. 

• Evaluate inpatient mental health overflow, ensure proper 

unit designation, and complete environmental planning to 

assure patient safety. 

• Conduct controlled substances (CS) inspections in 

accordance with VHA policy. 

• Correct all identified environment of care (EOC) findings 

within the pharmacy at the Jefferson Barracks (JB) 

division. 

• Correct the identified privacy concerns at the JB division. 

• Comply with VHA employment screening requirements. 

• Ensure that CPR training is documented in the electronic 

training record, as required by medical center policy. 

• Ensure that all providers privileged to administer moderate 

sedation have documentation of current training in airway 

management and cardiac arrhythmias. 

• Ensure that providers who administer moderate sedation 

obtain privileges in accordance with VHA policy. 

The medical center complied with selected standards in the 

following activity: 

• Survey of Healthcare Experiences of Patients (SHEP). 

This report was prepared under the direction of 

Verena Briley-Hudson, Director, Chicago Office of 

Healthcare Inspections. 

Comments The VISN and Medical Center Directors agreed with the 

findings and recommendations and submitted acceptable 

improvement plans. (See Appendixes A and B, 

pages 21–32, for the full text of the Directors’ comments.) 

We will follow up on all 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 St. Louis VA Medical Center, St. Louis, Missouri 

Introduction 

Profile Organization. The medical center is a two-division facility 

that provides a broad range of inpatient and outpatient health 

care services. The John Cochran (JC) division is located in 

midtown St. Louis, and the JB division is located in south 

St. Louis County. Outpatient care is also provided at three 

community based outpatient clinics in St. Charles and 

St. Louis, MO, and in Bellville, IL. The medical center is part 

of VISN 15 and serves a veteran population of about 

251,000 throughout the city of St. Louis, 7 counties in 

Missouri, and 14 counties in Illinois. 

Programs. The medical center provides inpatient and 

ambulatory medicine, surgery, psychiatry, neurology, and 

rehabilitation services in more than 65 subspecialties. It has 

143 hospital, 71 nursing home, and 50 domiciliary beds. 

Affiliations and Research. The medical center is affiliated 

with Saint Louis University and Washington University and 

provides training for 43 residents, as well as other 

disciplines, including diagnostic radiology, laboratory, 

nuclear medicine, neurology, and psychiatry. In fiscal year 

(FY) 2007, the medical center’s research program had 

14 projects and a budget of $1.3 million. Important areas of 

research included metabolism in aging, blood brain barrier 

and alcoholism, role of glutamate pathway in dementia, 

evaluation of stress response systems in Gulf War veterans, 

and vocal cord paralysis. 

Resources. In FY 2007, medical care expenditures totaled 

$326.7 million, and the medical care budget was 

$327.6 million. FY 2007 staffing was 1,806 full-time 

employee equivalents (FTE), including 172 physician and 

508 nursing FTE. 

Workload. In FY 2007, the medical center treated 

51,570 unique patients and provided 52,661 inpatient days in 

the hospital, 20,627 inpatient days in the Nursing Home Care 

Unit (NHCU), and 14,617 inpatient days in the domiciliary. 

The inpatient care workload totaled 8,326 hospital 

discharges, 773 NHCU discharges, and 129 domiciliary 

discharges. The average daily census, including NHCU 

patients, was 241. Outpatient workload totaled 

351,292 visits. 

VA Office of Inspector General 1 
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri 

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 six activities: 

• EOC.

• Follow-Up on Background Investigations and Security 

Clearances.

• Follow-Up on Moderate Sedation Practices.

• Pharmacy Operations.

• QM.

• SHEP.

The review covered medical center operations for FY 2007 

and FY 2008 through May 2, 2008, and was done in 

accordance with OIG standard operating procedures for CAP 

reviews. We followed up on select recommendations from 

our two most recent CAP reviews of the medical center 

(Combined Assessment Program Review of the St. Louis 

VA Medical Center, St. Louis, Missouri, Report 

No. 06-02818-100, March 14, 2007, and Combined 

VA Office of Inspector General 2 
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri 

Assessment Program Review of the VA Medical Center, 

St Louis, Missouri, Report No. 04-01893-148, June 2, 2005). 

We also followed up on recommendations from a report by 

VHA’s Office of the Medical Inspector (OMI) (Quality of Care 

Review, Veterans Affairs Medical Center, St. Louis, Missouri, 

January 22, 2008. In that report, the OMI made 

recommendations to improve the care for spinal cord 

injury/disorder (SCI/D) patients. 

We reviewed the medical center’s follow-up documentation 

and plans in response to the OMI recommendations and 

consider the medical center’s actions appropriate. Although 

construction of the satellite SCI/D unit is pending, we 

consider the OMI recommendations closed. 

During this review, we also presented fraud and integrity 

awareness briefings for 269 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 Strength 

Diversity Award 

Recipient

In FY 2006, the medical center received the Under Secretary 

for Health’s Diversity Award in Workforce Development and 

Succession Planning. The “School at Work” program, 

designed to enhance employee core competency skills for 

career mobility, and the “Read at Work” program, designed 

to enhance employee reading and writing skills, were key 

components in the Diversity Advisory Board’s selection of 

the medical center for this award. Since FY 2006, additional 

programs have been developed, including the “College at 

Work” program (onsite college credit classes for employees 

after work), the “Facility Leadership Enhancement and 

Development” program (a mentorship program to enhance 

employee leadership skills), and the “Industrial Technology” 

program (onsite engineering skills development through 

courses for employees). The medical center pays fees for

tuition and books for employees who enroll in any of these 

programs. Additionally, the medical center sponsors the 

VA Office of Inspector General 3 
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri 

“High School Partnerships” program, which provides 

instruction in biomedical engineering, pharmacy, and nursing 

as potential career choices for students. 

Results 

Review Activities With Recommendations 

Quality 

Management 

The purpose of this review was to evaluate whether the 

medical center’s QM program provided comprehensive 

oversight of the quality of care and whether senior managers 

actively supported the program’s activities. We interviewed 

the medical center’s Director, the Chief of Staff, and key 

employees. Senior managers were supportive of 

performance improvement (PI) activities. We reviewed 

plans, policies, committee minutes, and other relevant 

documents for FY 2007 and identified six program areas that 

required further management attention. We identified two 

program areas from our March 14, 2007, CAP review that 

will remain open. Additionally, we followed up on delinquent 

operative reports discovered during a recent OIG inspection 

at the medical center. 

Credentialing and Privileging Process. VHA policy1 requires 

that the reprivileging process include an appraisal of 

professional performance, judgment, and clinical/technical 

competence and skills based in part on clinician-specific PI 

activities. Our March 14, 2007, CAP review identified that PI 

data used during the reprivileging process needed to be 

expanded to include more meaningful areas, such as 

medication usage and medical record documentation. We 

were informed that the medical center’s new PI policy was 

recently approved and will include more meaningful data 

collection. This recommendation will remain open until the 

process has been implemented and monitored. 

VHA policy2 requires that all clinically active staff have 

current CPR training. We reviewed 12 randomly selected 

C&P folders of newly appointed clinicians and clinicians who 

had been reprivileged in the past 12 months. We found that 

of the seven newly appointed clinicians, five did not have 

 

1 VHA Handbook 1100.19, Credentialing and Privileging, March 6, 2001. 2 VHA Directive 2002-046, Staff Training in Cardiopulmonary Resuscitation and Advanced Cardiac Life Support, 

July 31, 2002.

VA Office of Inspector General 4 
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri 

current CPR training. Of the five reprivileged clinicians, two 

did not have current CPR training. 

We were told during our interview with credentialing staff that 

providers contracted for 1 year were given clinical privileges 

for a total of 2 years. This was partly due to the fact that the 

C&P process was performed every 2 years. 

Peer Review Process. Once the need for a PR is 

determined, VHA3 and medical center policies4 require that 

initial reviews be completed within 45 days and that PR 

Committee evaluations be completed within 120 days. The 

PR process needed to be improved to ensure timely 

completion of reviews. Of the 109 PRs performed during 

FY 2007, 20 exceeded 45 days for completion of the initial 

review, and 6 exceeded 120 days for final evaluation by the 

committee. 

PR data was trended for outcome levels and level changes; 

however, PR data was not trended for follow-up action items 

or for recommendations that resulted from the PRs. This 

was a recommendation from our prior CAP review and will 

remain open until completed. 

Utilization Management Program. VHA policy5 defines 

program components that must be in place to perform UM 

functions. The medical center did not comply with VHA 

policy regarding IRR6 reviews. We were informed during our 

interview with UM staff that IRR reviews had been conducted 

in the past; however, they were not being performed at the 

time of our review. 

Medical Record Review. VHA policy7 requires that a 

process be in place to monitor the copying and pasting of 

text into the electronic medical record. The medical center’s 

policy and bylaws also address this issue; however, no 

monitoring was performed to ensure compliance. 

Operative and Invasive Procedures. Moderate sedation 

outcomes and the use of reversal agents were not monitored 

consistently during FY 2007. Additionally, moderate 

 

3 VHA Directive 2004-054, Peer Review for Quality Management, September 29, 2004. 4 Medical Center Memorandum 00-65, Peer Review for Quality Management, March 24, 2005.

5 VHA Directive 2005-040, Utilization Management Policy, September 22, 2005. 6 IRR is the extent to which two or more individuals agree.

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

VA Office of Inspector General 5 
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri 

sedation data was not critically analyzed to identify 

opportunities for improvement. 

Delinquent Operative Reports. During a recent OIG 

inspection at the medical center, it was discovered that as of 

April 20, 2008, 117 operative reports had not been 

completed in a timely manner. One of the operative reports 

on this list dated back to 2004. Joint Commission standards 

and VHA8 and medical center9 policies require that an 

operative report be completed following a procedure. As of 

May 6, 2008, 53 operative reports remained delinquent. 

Patient Flow. There was no documented plan or process for 

patients receiving care in temporary bed locations. 

Additionally, there was no documented plan for the delivery 

of services to non-admitted patients placed in overflow 

locations within the medical center. 

Recommendation 1 We recommended that the VISN Director ensure that the 

Medical Center Director requires that performance data is 

used in the C&P process, in accordance with VHA policy. 

The VISN and Medical Center Directors concurred with the 

finding and recommendation. Beginning September 5, 2008, 

the service chief will ensure that PI data used for 

reprivileging will be available at each level of review and 

approval. 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 

Medical Center Director requires that all clinically active staff 

complete CPR training, in accordance with VHA policy. 

The VISN and Medical Center Directors concurred with the 

findings and recommendation. The Administrative 

Officer/Business Manager (AO/BM) will obtain copies of CPR 

cards and forward them to the Credentialing Coordinator for 

entry into the medical center’s privilege database. The Chief 

of Staff will notify licensed independent practitioners (LIPs) 

without evidence of CPR training to obtain CPR training.

 

8 VHA Handbook 1907.01.

9 Medical Center Memorandum 11-04, Medical Staff Bylaws and Rules and Regulations, 

December 17, 2006, and Medical Center Memorandum FMS MR-01, Management of Health Records, 

February 12, 2007.

VA Office of Inspector General 6 
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri 

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 

Medical Center Director requires that contracted providers 

are not privileged beyond their association with the medical 

center. 

The VISN and Medical Center Directors concurred with the 

finding and recommendation. The Chief of Human 

Resources (HR) will revise the medical center’s policy to 

state that privileges will not exceed the length of the contract. 

The improvement plan is acceptable, and we will follow up 

on the completion of the planned actions. 

Recommendation 4 We recommended that the VISN Director ensure that the 

Medical Center Director requires that PRs are timely 

conducted, in accordance with VHA policy. 

The VISN and Medical Center Directors concurred with the 

findings and recommendation. The Chief of QM and the 

Risk Manager created additional fields and reports for the 

medical center’s PR tracking database to identify pending 

reviews and capture follow-up actions and 

recommendations. The improvement plan is acceptable, 

and we will follow up on the completion of the planned 

actions. 

Recommendation 5 We recommended that the VISN Director ensure that the 

Medical Center Director meets VHA requirements for IRR 

reviews for the UM program. 

The VISN and Medical Center Directors concurred with the 

finding and recommendation. The Chief of QM established a 

procedure to complete IRR reviews for UM/utilization review 

staff on a quarterly basis. 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 

Medical Center Director meets VHA requirements for 

copying and pasting text into the electronic medical record. 

The VISN and Medical Center Directors concurred with the 

finding and recommendation. The Chief of Health 

Information Management Service and the Chair of the 

Medical Records Review Committee will develop a 

VA Office of Inspector General 7 
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri 

procedure for monitoring the copying and pasting of text into 

the electronic medical record. 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 

Medical Center Director requires that moderate sedation 

data be critically analyzed, trended, and monitored. 

The VISN and Medical Center Directors concurred with the 

findings and recommendation. The Chief of Staff, with 

approval of the Executive Committee of the Medical Staff, 

established the Invasive Procedure Committee to 

standardize the monitoring of the quality of care and 

outcomes of non-operating room invasive procedures. The 

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

completion of the planned actions. 

Recommendation 8 We recommended that the VISN Director ensure that the 

Medical Center Director requires that operative reports be 

completed in accordance with VHA policy. 

The VISN and Medical Center Directors concurred with the 

finding and recommendation. The Chief of Surgery will 

develop a standard operating procedure to monitor timely 

completion of operative notes and actions for 

non-compliance. The improvement plan is acceptable, and 

we will follow up on the completion of the planned actions. 

Recommendation 9 We recommended that the VISN Director ensure that the 

Medical Center Director requires that processes are in place 

to address patient flow in temporary bed and overflow 

locations. 

The VISN and Medical Center Directors concurred with the 

findings and recommendation. The Associate Director for 

Patient and Nursing Service will establish a workgroup to 

develop a plan for the delivery of services to non-admitted 

patients in overflow locations. 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 medical 

center had established a comprehensive EOC program that 

contributed to a safe and clean environment, complied with 

safety standards and guidelines, maintained an effective IC 

VA Office of Inspector General 8 
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri 

program, and identified hazards that might pose a safety 

threat to patients and staff on locked mental health units. 

At the JC division, we inspected the medical and surgical 

units, the Yellow Clinic (ambulatory care), the emergency 

room, and the Veterans Canteen Service dining area. At the 

JB division, we inspected the locked acute psychiatric units 

and the locked geriatric psychiatric unit. We also followed up 

on recommendations from our March 14, 2007, CAP review. 

Refrigerator temperature monitoring was again problematic. 

Managers were responsive to identified environmental 

concerns. The IC program monitored, trended, and 

analyzed data and reported results to clinicians for quality 

improvements. The Multidisciplinary Safety Inspection Team 

conducted risk assessments of the three locked acute 

psychiatric units and the one locked geriatric psychiatric unit. 

Staff were pursuing corrective actions for the identified 

vulnerabilities. The following deficiencies required further 

management attention. 

Infection Control. Emergency call system cords must be 

accessible and easily cleaned as they are often located in 

shower areas and near commodes and sinks. The medical 

center was in the process of changing rope-style cords to 

plastic cords; however, we noted that several cords were not 

accessible from the floor. Additionally, we noted that tape 

was used as a pull cord for an overbed light. 

Medication and nourishment refrigerator temperatures must 

be monitored daily to ensure that the contents are safe. 

When a refrigerator is found to be out of the acceptable 

temperature range, an employee needs to initiate corrective 

action (such as adjusting the temperature control or creating 

a work order for repair). The action should be documented 

in the refrigerator log so that other employees are aware of 

what was done. We noted that staff did not consistently 

document actions taken when refrigerator temperatures were 

out of range. This was a repeat finding from the 

March 14, 2007, CAP review. We also noted some 

refrigerators were frequently problematic and needed to be 

replaced. 

Medications were stored in an automated dispensing 

machine in a secured room on the locked geriatric 

psychiatric unit at the JB division. Upon entering the area, 

we noted that the temperature in the room was significantly 

VA Office of Inspector General 9 
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri 

warmer than the hallway temperature. We recommended 

that immediate action be taken to determine the cause and 

to ensure that medications were not compromised. 

Patient care equipment and furniture needs to be regularly 

inspected, and items with compromised surfaces need to be 

repaired or removed from service. We identified two 

wheelchairs with tattered armrests and several damaged 

pads on chairs in an equipment storage room. 

Storage areas need to be maintained so that clean and dirty 

items are separated. We identified several storage rooms 

that contained a mixture of items, such as clean linens 

stored with dirty patient care equipment. 

Safety. We observed that individual ceiling panels were 

used in the hallways and dayroom areas of the locked 

psychiatric units. These panels could potentially be 

removed. The shower control fixture in the women’s shower 

area on one of the locked psychiatric units needed to be 

replaced as it could be used as an anchor point for a noose. 

Additionally, the nurses’ station door on this unit was open, 

potentially allowing unauthorized entry to the area. 

Needles and a hemostat were found in unlocked carts and 

totes in the hallway of a medical unit. These items needed 

to be secured. 

Medications and cleaning products must be secured at all 

times. Lidocane10 was left on a bedside stand in a patient 

room. Saline11 was found in an unlocked cart in a hallway. 

Sodium chloride12 was found near a sink in a patient 

restroom. A bottle of isopropyl alcohol13 and a cleaning 

product were left on top of a shredding receptacle near the 

nurses’ station on a medical unit. We also noted that this 

medical unit’s medication room door lock was inoperable, 

allowing unrestricted access to the room. 

System panel boxes and shut-off valves must be easily 

accessible to staff for emergency access and repair. We 

noted that many of these panel boxes and shut-off valves 

were located in storage rooms on patient care units. Items in 

 

10 This medication is used as a local anesthetic.

11 This is a sterile solution of sodium chloride in water that is commonly used for intravenous infusion and 

irrigation.

12 This is an agent used in intravenous solutions as a source of electrolytes, hydration, and irrigation. 13 This product is also commonly known as rubbing alcohol and is used for sterilization.

VA Office of Inspector General 10 
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri 

the storage rooms were placed in a manner that obstructed 

access. We also noted that many storage rooms had items 

placed directly on the floor, which is a Life Safety Code 

issue. 

Oxygen tanks must be secured and stored so that staff may 

quickly recognize if the tanks are full or empty. An oxygen 

tank located in a secured room on one of the locked 

psychiatric units was not clearly identifiable as full or empty. 

Emergency crash cart inspections for each cart are required 

to be documented in a log. Documentation includes the 

number on the plastic locking tag that secures medications in 

the cart. Upon inspection of the logs, we noted that staff 

incorrectly transcribed the number of one of the plastic 

locking tags, and in a second crash cart log, the documented 

tag number was illegible. We also identified that crash cart 

checks were not being done as frequently as directed by 

medical center policy.14

On the locked geriatric psychiatric unit, there were 

shower/restroom areas shared by adjoining patient rooms. 

Showers operated by push button, and they remained on for 

a timed interval. We observed that water did not properly 

drain and flowed out of the room onto the floors in the patient 

rooms. Nursing staff reported that all shared showers have 

this problem. The pooling water created an unsafe condition 

that could result in a fall. 

Patient Privacy. Federal law15 requires that sensitive patient 

information be secured from unauthorized access. 

Clipboards with full patient names and social security 

numbers were hanging from handrails outside patient rooms, 

left on the tops of carts in hallways, and hanging from patient 

beds. Patient information was also observed on top of an 

unattended medication cart in a hallway. A white marker 

board with patient names, located in a nurses’ station on a 

patient unit, could be viewed from the hallway. Additionally, 

patient information was found in holding devices located 

outside examination rooms in the ambulatory care area. 

Psychiatric Unit Designation. The locked geriatric psychiatric 

unit at the JB division also serves as an overflow location for 

acute psychiatric patients when the three locked acute 

 

14 Medical Center Memorandum 11-13, Emergency Resuscitation (Code K), August 31, 2004. 15 Health Insurance Portability and Accountability Act of 1996.

VA Office of Inspector General 11 
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri 

psychiatric units are full. This unit can accommodate 

16 patients, and on the day of our inspection, there were 

7 acute and 3 geriatric patients. Nursing staff reported that 

this unit may have 7 to 16 acute patients daily. If this unit 

treats acute patients, additional environmental 

considerations are warranted. For example, many of the 

beds on the unit are hospital beds with handrails that could 

serve as anchor points and are not appropriate for acute 

patients who may intend to harm themselves. 

Recommendation 10 We recommended that the VISN Director ensure that the 

Medical Center Director requires that identified IC 

vulnerabilities be corrected. 

The VISN and Medical Center Directors concurred with the 

findings and recommendation. Engineering staff will install 

appropriate cords and heating, ventilation, and air 

conditioning tie-ins and have developed a contract to install a 

monitoring system for refrigerators and freezers in the 

medical center. Patient care equipment will be inspected 

during EOC rounds. Nursing staff will inspect all storage 

areas. 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 

Medical Center Director requires that safety vulnerabilities be 

corrected. 

The VISN and Medical Center Directors concurred with the 

findings and recommendation. Engineering staff will replace 

ceiling tiles and grids, the shower control fixture, and the 

nursing station door. Nursing staff will inspect all storage 

areas. The improvement plan is acceptable, and we will 

follow up on the completion of the planned actions. 

Recommendation 12 We recommended that the VISN Director ensure that the 

Medical Center Director requires that identified patient 

privacy vulnerabilities be corrected. 

The VISN and Medical Center Directors concurred with the 

findings and recommendation. Nursing staff will eliminate 

the clipboards with patient information at the patients’ 

bedsides. Patient information will no longer be placed in 

holding devices. The improvement plan is acceptable, and 

we will follow up on the completion of the planned actions.

VA Office of Inspector General 12 
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri 

Recommendation 13 We recommended that the VISN Director ensure that the 

Medical Center Director requires an evaluation of inpatient 

mental health overflow, proper unit designation, and 

environmental planning to assure patient safety. 

The VISN and Medical Center Directors concurred with the 

findings and recommendation. The Associate Chief of Staff 

will evaluate the overflow location within mental health. 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 VA 

health care facilities had adequate controls to ensure the 

security and proper management of CS and the pharmacies’ 

internal physical environments. We also determined whether 

clinical managers had processes in place to monitor patients 

prescribed multiple medications to avoid polypharmacy, 

especially in vulnerable populations. 

We reviewed VHA handbooks16 governing pharmacy and 

CS security, and we assessed whether the medical center’s

policies and practices were consistent with VHA regulations. 

We inspected inpatient and outpatient pharmacies for 

security, EOC, and IC concerns, and we interviewed 

Pharmacy Service and Police and Security Service 

personnel. Additionally, we interviewed staff to determine if 

clinical pharmacists monitored patients prescribed multiple 

medications to avoid polypharmacy. 

Pharmacy Controls. Our review determined that the medical 

center had appropriate policies and procedures to ensure the 

security of the pharmacies and CS. Training records 

showed that the CS Coordinator and inspectors received 

appropriate training to execute their duties. However, during 

our inspection, we found that CS inspectors did not verify 

10 percent of all hard copy prescriptions for Schedule II17

drugs, as required by VHA policy. We were told during our 

interview with the CS Coordinator that inspectors now verify 

50 hard copy prescriptions monthly, which equals or exceeds 

10 percent. 

 

16 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.

17 This category of drugs has a strong potential for abuse or addiction but has legitimate medical uses. Some 

examples are opium, morphine, and cocaine.

VA Office of Inspector General 13 
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri 

The medical center has 27 CS locations. During the past 

6 months, 8 of 164 inspections were not completed in 

accordance with VHA policy. 

Internal Environment of Care. Internal pharmacy EOC was 

clean and well maintained at the JC division. However, there 

were areas at the JB division that required further 

management attention. We found soiled ceiling tiles with 

numerous unsealed penetrations throughout the pharmacy. 

The floors were heavily stained and appeared dirty. Several 

ceiling vents were covered with heavy dust, dirt, and what 

appeared to be mold. One large vent, mounted on the 

ceiling in the center of the area, was apparently broken and 

not in use. The door to this unit was open and covered with 

excessive dirt and dust. These areas posed IC concerns. 

Auditory and Visual Privacy. The outpatient waiting room 

area at the JB division is small. The room has seating for 

patients awaiting pharmacy pickup, and there are two clinical 

pharmacists stationed in this same area performing 

counseling. There is no privacy for patients being 

counseled, which is in violation of Federal law.18

Polypharmacy. 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 

 

18 Health Insurance Portability and Accountability Act of 1996.

VA Office of Inspector General 14 
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri 

treat adverse drug reactions.19 Some literature suggests 

elderly and mental health patients are among the most 

vulnerable populations for polypharmacy.20

Managers informed us during our interview that the medical 

center has a process in place for monitoring polypharmacy. 

The medical center operates an outpatient medication 

management clinic. Also, pharmacists document any 

polypharmacy concerns and suggestions for primary care 

providers in the patients’ medical records. 

Recommendation 14 We recommended that the VISN Director ensure that the 

Medical Center Director requires that CS inspections are 

completed in accordance with VHA policy. 

The VISN and Medical Center Directors concurred with the 

finding and recommendation. The CS Coordinator modified 

the CS inspection tracking sheet to include the date each 

inspector plans to complete his or her inspections each 

month. The improvement plan is acceptable, and we will 

follow up on the completion of the planned actions. 

Recommendation 15 We recommended that the VISN Director ensure that the 

Medical Center Director corrects all identified EOC findings 

within the pharmacy at the JB division. 

The VISN and Medical Center Directors concurred with the 

findings and recommendation. Engineering staff replaced 

soiled ceiling tiles and sealed ceiling penetrations in the 

pharmacy. Engineering staff will develop a project to replace 

the flooring. The improvement plan is acceptable, and we 

will follow up on the completion of the planned actions. 

Recommendation 16 We recommended that the VISN Director ensure that the 

Medical Center Director corrects the identified privacy 

concerns at the JB division. 

The VISN and Medical Center Directors concurred with the 

finding and recommendation. The pharmacy manager 

removed some of the seating units to increase the distance 

between patients waiting for the pharmacist and those being 

counseled by the pharmacist. The improvement plan is 

 

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

December 2004.

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

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

January 2006.

VA Office of Inspector General 15 
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri 

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

planned actions. 

Follow-Up on 

Background 

Investigations and 

Security 

Clearances

The purpose of the review was to follow up on background 

investigation and security clearance findings from the 

June 2, 2005, CAP review. During that review, we found that 

a Nuclear Medicine employee with programmer privileges, 

the Chief of Staff, and the Chief of Police did not have 

security clearances congruent with their high-risk positions. 

On August 14, 2006, the Deputy Under Secretary for Health 

for Operations and Management sent a memorandum to all 

Network Directors to clarify screening requirements and 

establish the process by which documentation of the 

screening of backgrounds of VHA appointees, contractors, 

and volunteers will be accomplished. VHA requires the use 

of a screening checklist for appointments to positions on a 

full-time, part-time, and intermittent basis. This includes all 

on-station fee basis positions, consultants, attendings, 

without compensation positions, residents, and students. 

We reviewed Official Personnel Folders and HR 

Management Service records for 31 physicians who were 

credentialed and privileged to practice at the medical center. 

Our sample included fee basis and without compensation 

providers. There were issues with six physicians’ records. 

Staff were unable to provide background investigation 

verifications for three of the physicians—two fee basis and 

one without compensation. Additionally, there was no 

documentation of background investigations or security 

clearances for three physicians from our sample who had 

worked for the medical center for 20 years or more and were 

reprivileged during the last 12 months. 

Recommendation 17 We recommended that the VISN Director ensure that the 

Medical Center Director complies with VHA employment 

screening requirements. 

The VISN and Medical Center Directors concurred with the 

findings and recommendation. The Chief of HR will revise 

the “Standard Operating Procedure on Background 

Investigation” to include the appropriate filing of documents 

when an employee moves from a staff position to a without 

compensation or fee basis position. The improvement plan 

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

planned actions. 

VA Office of Inspector General 16 
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri 

The purpose of this review was to follow up on moderate 

sedation findings from the March 14, 2007, CAP review. 

During that review, we found that managers needed to 

update medical center policy to ensure that all clinical 

providers have CPR training and monitor compliance. 

Follow-Up on 

Moderate Sedation 

Practices

We reviewed the training records of 22 providers currently 

privileged to administer moderate sedation. Seven providers 

did not have evidence of current CPR training. VHA21 and 

medical center22 policies require that all clinical staff have 

CPR training. Moreover, medical center policy requires that 

this training be documented in the electronic training record. 

We found that of the 15 employees who had current training, 

only 5 had entries in their electronic training records. 

Additionally, VHA23 and medical center24 policies require 

training in airway management and cardiac arrhythmias for 

those who administer moderate sedation. We found that 

14 of the 22 providers did not have documentation of this 

training. This is a repeat finding from the June 2, 2005, and 

the March 14, 2007, CAP reviews. Recommendation 2 on 

page 7 of this report addresses the CPR training portion of 

this finding. 

Further, we requested the approved reprivileging 

applications for the 22 providers reviewed. We found that 

three providers had not requested privileges for moderate 

sedation administration; therefore, they had not been 

approved by the medical center’s Director, as required by 

VHA policy.

Recommendation 18 We recommended that the VISN Director ensure that the 

Medical Center Director requires that CPR training be 

documented in the electronic training record, in accordance 

with medical center policy. 

The VISN and Medical Center Directors concurred with the 

findings and recommendation. CPR training for LIPs will be 

entered and tracked in the medical center’s privilege 

database. The improvement plan is acceptable, and we will 

follow up on the completion of the planned actions. 

 

21 VHA Directive 2002-046.

22 Medical Center Memorandum 11-46, Staff Training in Cardiopulmonary Resuscitation and Advanced Cardiac 

Life Support, December 20, 2006.

23 VHA Directive 2006-023, Moderate Sedation By Non-Anesthesia Providers, May 1, 2006. 24 Chief of Staff Standard Operating Procedure No. 11-087, Sedation By Non Anesthesia Providers, April 30, 2008. 

VA Office of Inspector General 17 
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri 

Recommendation 19 We recommended that the VISN Director ensure that the 

Medical Center Director requires that all providers privileged 

to administer moderate sedation have documentation of 

current training in airway management and cardiac 

arrhythmias. 

The VISN and Medical Center Directors concurred with the 

finding and recommendation. The AO/BM will review each 

provider’s file for evidence of training in airway management 

and cardiac arrhythmias. Providers without evidence of 

training will be requested to provide evidence of training 

within 30 days. The improvement plan is acceptable, and we 

will follow up on the completion of the planned actions. 

Recommendation 20 We recommended that the VISN Director ensure that the 

Medical Center Director requires that providers who 

administer moderate sedation obtain privileges in 

accordance with VHA policy. 

The VISN and Medical Center Directors concurred with the 

finding and recommendation. The Credentialing Coordinator 

and the Chief of QM will review the list of all providers with 

invasive procedure privileges to identify those who did not 

request sedation privileges. The improvement plan is 

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

planned actions. 

Review Activities Without Recommendations 

Survey of 

Healthcare 

Experiences of 

Patients 

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

medical facilities use the quarterly or semi-annual 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 (PM) target results for patients 

reporting overall satisfaction of “very good” or “excellent” at 

76 percent for inpatients and 77 percent for outpatients. 

Figure 1 below and Figure 2 on the next page show the 

SHEP PM results for inpatients and outpatients, respectively. 

VA Office of Inspector General 18 
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri 

50

55

60

65

70

75

80

85

90

95

100

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

Quarter Reported

Percent Reporting Overall Quality as

 Very Good or Excellent

Facility

VISN

National

Exceeds 

Target

Meets 

Target

Figure 1: ST. LOUIS VA MEDICAL CENTER

INPATIENT OVERALL QUALITY

 BY QUARTER

ST. LOUIS VA MEDICAL CENTER

OUTPATIENT OVERALL QUALITY

 BY QUARTER

50

55

60

65

70

75

80

85

90

95

100

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

Quarter Reported

Percent Reporting Overall Quality as

 Very Good or Excellent

Facility

VISN

National

Figure 2:

Exceeds 

Target

Meets 

Target

VA Office of Inspector General 19 
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri 

The medical center has not met or exceeded the 76 percent 

threshold in the last 8 quarters of available data for inpatient 

overall quality. The medical center scored above the 

77 percent threshold in 2 of the last 8 quarters of available 

data for outpatient overall quality. Managers had identified 

opportunities for improvement based on the SHEP scores 

and had developed an action plan targeting specific areas. 

The action plan was implemented, and there is evidence of 

ongoing activities, including evaluation of the plan for 

effectiveness. Additionally, the medical center presented 

local data indicating improved scores; therefore, we made no 

recommendations.

VA Office of Inspector General 20 
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri

Appendix A

VISN Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: July 14, 2008 

From: Director, VA Heartland Network VISN 15 (10N15) 

Subject: Combined Assessment Program Review of the St. Louis 

VA Medical Center, St. Louis, Missouri 

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

Director, Management Review Service (10B5) 

I have reviewed the report from the Inspector General’s Combined 

Assessment Program (CAP) of the St. Louis VA Medical Center. We 

concur with all the findings and action plans to the recommendations 

outlined in the report. 

PETER L. ALMENOFF, MD, FCCP 

VA Office of Inspector General 21 
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri 

Appendix B

Medical Center Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: July 8, 2008 

From: Director, St. Louis VA Medical Center (657/00) 

Subject: Combined Assessment Program Review of the St. Louis 

VA Medical Center, St. Louis, Missouri 

To: Director, VISN 15 (10N15) 

Attached is the St. Louis VA Medical Center response and actions plan to 

the OIG report from the Combined Assessment Program that was 

conducted on May 5–9, 2008. 

 (original signed by:) 

GLEN E. STRUCHTEMEYER 

VA Office of Inspector General 22 
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri 

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 performance data is used in 

the C&P process, in accordance with VHA policy. 

Concur Target Date: September 30, 2008 

The medical center revised the Medical and Dental Staff Performance 

Improvement Plan with approval by the ECMS on May 2, 2008. This 

revision includes clinician-specific PI data for use in the reprivileging 

process in a standardized reporting format. The PI Committee has the 

responsibility for providing oversight and monitoring the implementation of 

the plan. The Chief of QM will ensure the new standardized report will be 

populated for each provider and distributed to the provider and the service 

chief by September 5, 2008. The service chief will document the PI data 

utilized for the reprivileging process in the service chief approval section of 

VetPro (VHA’s electronic credentialing system) beginning August 1, 2008. 

The service chief will ensure the PI data used for reprivileging will be 

available at each level of review and approval beginning 

September 5, 2008. 

Recommendation 2. We recommended that the VISN Director ensure 

that the Medical Center Director requires that all clinically active staff 

complete CPR training, in accordance with VHA policy. 

Concur Target Date: August 30, 2008 

The Chief of QM will review and revise the Medical Center Memorandum 

(MCM) 11-46 “Staff Training in Cardiopulmonary Resuscitation and 

Advance Cardiac Life Support” to clarify the requirements for LIP by 

July 30, 2008. This includes: initial appointments must have evidence of 

completion of CPR, renewal appointments will not be processed without 

evidence of CPR training; and evidence of training will be tracked in the 

medical center’s privilege database. Chief of Staff will communicate this 

clarification to the medical and dental staff by August 1, 2008. AO/BM will 

review a list of all LIPs for status of CPR training by August 1, 2008. The 

AO/BM will obtain a copy of the CPR card and forward it to the 

Credentialing Coordinator for entry in the medical center’s privilege 

database by August 15, 2008. The Chief of Staff will notify LIPs without 

VA Office of Inspector General 23 
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri 

evidence of CPR training and resources to obtain CPR training. The 

consequences of not meeting the CPR training requirement will result in 

suspension of privileges. The Associate Chief of Staff for Education will 

develop a plan to ensure LIPs have routine access to CPR training at the 

medical center or through other training sites by July 23, 2008. The 

Credentialing Coordinator will generate a monthly report of LIPs with CPR 

expiration dates within the next 90 days and distribute it to the service 

chiefs’ AO/BM for action beginning August 30, 2008. The Credentialing 

Coordinator will revise the credentialing packet letter by including the CPR 

training requirement. The Chief of Staff will report each month to the 

medical center Director the status of LIP’s CPR training compliance and 

action plan to address patient care needs impacted by provider 

non-compliance beginning July 30, 2008. 

Recommendation 3. We recommended that the VISN Director ensure 

that the Medical Center Director requires that contracted providers are not 

privileged beyond their association with the medical center. 

Concur Target Date: August 8, 2008 

The Chief of HR completed a review of all privileged contracted staff to 

determine those who had been granted privileges past the contract end 

date on June 30, 2008. The Chief of HR will revise the procedure for 

processing contracted provider privileges to coincide with the contract 

(January 1 to December 31) by July 30, 2008. Contracted providers who 

have privileges beyond the expiration of the contract will be notified of the 

change in the privilege expiration date. By August 8, 2008, the 

Credentialing Coordinator will inform the affected providers via letter of the 

expiration of their privileges on December 31, 2008. The Chief of HR will 

revise MCM 11-07 “Credentialing and Privileging” to state that privileges 

will not exceed the length of the contract by August 8, 2008. 

Recommendation 4. We recommended that the VISN Director ensure 

that the Medical Center Director requires that PRs are timely conducted, in 

accordance with VHA policy. 

Concur Target Date: September 30, 2008 

During the 4th quarter of FY 2007 the Chief of QM and the RM completed 

an in-depth analysis of PRs completed during the 1st through 3rd quarter of 

FY 2007 to identify reasons for cases that were greater than 45 days initial 

and greater than 120 days overall processing time. It was identified when 

the initial reviews are completed within 30 days or less all the timeframes 

are met. The Chief of QM and the RM implemented the following actions 

to improve the timeliness of PRs: 1) Revision of review request letter to 

ask for completion of initial review within 14 days of date of letter. 

2) Addition of fields and reports in the PR Tracking database to identify the 

VA Office of Inspector General 24 
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri 

number of pending in initial review, number assigned to each reviewer, 

14 day and 21 day reminder report. 3) Revised reminder procedure by the 

RM to reviewers. 4) Identified and trained additional cadre of reviewers. 

These actions were completed October 1, 2007. The RM monitors the 

timeliness of the PR process and reports to the PR Committee and ECMS 

at least quarterly. Since implementation, improvement has been seen. 

The number of initial reviews completed within 45 days through the 

3rd quarter of FY 2008 is 103 of 107. The four initial reviews greater than 

45 days occurred early in the 1st quarter. The number of final reviews by 

the committee within 120 days is 107 of 107. None has exceeded 

120 days. 

The Chief of QM and the RM identified and created additional fields for the 

medical center’s PR tracking database to capture follow-up actions and 

recommendations on June 17, 2008. The 3rd quarter FY 2008 PR report 

to ECMS will include trended data for follow-up actions and 

recommendations. 

Recommendation 5. We recommended that the VISN Director ensure 

that the Medical Center Director meets VHA requirements for IRR reviews 

for the UM program. 

Concur Target Date: July 15, 2008

The Chief of QM established a procedure to complete IRR reviews for 

each utilization management/utilization review staff on a quarterly basis 

beginning June 17, 2008. It will include a review of at least 10 admissions 

and 10 continued stay reviews using InterQual Criteria (screening 

guidelines with respect to medical appropriateness of healthcare 

services). Results of the IRR review will be shared with the individual 

reviewed and opportunities for improvement will be addressed. The Chief 

of QM will provide a report of the summary of the IRR reviews each 

quarter beginning July 15, 2008. 

Recommendation 6. We recommended that the VISN Director ensure 

that the Medical Center Director meets VHA requirements for copying and 

pasting text into the electronic medical record. 

Concur Target Date: September 30, 2008

The Chief of HIMS and the Chair of MRRC will develop a procedure for 

monitoring, copying, and pasting text into the electronic medical record by 

August 1, 2008. Monitoring according to this procedure will begin 

August 1, 2008. The Chief of HIMS and the Chair of MRRC will report the 

results and analysis of copy and paste monitor to the MRRC beginning 

September 2008. As opportunities for improvement are identified, 

VA Office of Inspector General 25 
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri 

appropriate actions will be taken and tracked by the MRRC beginning 

September 2008. 

Recommendation 7. We recommended that the VISN Director ensure 

that the Medical Center Director requires that moderate sedation data be 

critically analyzed, trended, and monitored. 

Concur Target Date: September 30, 2008 

During the 4th quarter of FY 2007, the Chief of Staff and Chief of QM 

completed a review of the medical center’s procedures to monitor sedation 

practices. A fragmented process of each service’s monitoring and taking 

action was identified. This fragmented process led to the lack of trended 

sedation outcomes and use of reversals in FY 2007. The Chief of Staff 

with approval of the ECMS established the IPC to standardize the 

monitoring of quality care and outcomes of non-OR invasive procedures 

(MCM 00-12.67 “Invasive Procedure Committee”). The IPC defined the 

sedation outcome measures for routine collection, analysis and 

identification of opportunities for improvement. These measures were 

collected, trended, and analyzed to identify opportunities for improvement 

by service and aggregated on a medical center level beginning 

October 1, 2007. Data has been consistently collected, trended, and 

analyzed to identify opportunities for improvement in FY 2008. 

Recommendation 8. We recommended that the VISN Director ensure 

that the Medical Center Director requires that operative reports be 

completed in accordance with VHA policy. 

Concur Target Date: July 30, 2008 

On April 21, 2008, the Chief of Staff met with the Chief of Surgery and 

surgery attending staff to educate and reinforce the requirements of timely 

completion of operative reports within 8 hours of the completion of the 

surgery. Providers with delinquent operative reports were informed that 

OR time would be suspended until delinquent operative notes were 

completed. Beginning April 21, 2008, a daily report of delinquent 

operative reports was generated by the Surgery Service Administrative 

Officer or designee. Providers were given a list of delinquent operative 

report to complete during designated administrative time. The Chief of 

Surgery will develop a standard operating procedure to monitor timely 

completion of operative notes and actions for non-compliance by 

July 30, 2008. 

Recommendation 9. We recommended that the VISN Director ensure 

that the Medical Center Director requires that processes are in place to 

address patient flow in temporary bed and overflow locations. 

Concur Target Date: September 15, 2008 

VA Office of Inspector General 26 
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri 

On June 30, 2008, the ADPNS, in conjunction with the Chief of Staff, 

completed a review of patient care areas to identify temporary bed 

locations where patients would overflow. The ADPNS will establish a 

workgroup to develop a plan for the delivery of services to non-admitted 

patients in overflow locations by August 30, 2008. This workgroup will 

include representatives from logistics, pharmacy, laboratory, radiology, 

food & nutrition, housekeeping, nursing, informatics, quality management, 

utilization management and medical staff. Education will be provided to 

staff and supervisors of the identified temporary bed locations and the 

services identified in the plan by September 15, 2008. 

Recommendation 10. We recommended that the VISN Director ensure 

that the Medical Center Director requires that identified IC vulnerabilities 

be corrected. 

Concur Target Date: November 30, 2008 

Engineering staff canvassed all patient bathrooms to identify locations 

where rope-style cords and to check the length of cords to ensure they are 

accessible from the floor. All rope-style or short cords were replaced by 

May 19, 2008. 

Engineering staff will canvass all patient rooms to identify overbed lights 

with tape used as a pull cord and will replace with the appropriate pull cord 

by July 30, 2008. 

Engineering staff has developed a contract to install a centrally monitored 

system to observe all patient care refrigerators and freezers in the medical 

center on June 30, 2008. Full implementation of the system will be 

completed by October 31, 2008. The Environment of Care Committee 

(EOCC) will provide oversight and monitor this project. As a component of 

the project, engineering staff will evaluate patient care refrigerators to 

identify for replacement those refrigerators having frequent problems. 

Education to reinforce the current patient care refrigerator monitoring 

policy was completed with supervisors and managers on May 16, 2008. 

Engineering staff installed HVAC drop into the medication room on the 

geriatric psychiatric unit at JB division on May 30, 2008. Engineering staff 

will complete a HVAC study of all medication and supply areas to identify 

areas not tied into the HVAC system by September 1, 2008. Engineering 

staff will install HVAC tie-in for the identified areas by November 30, 2008. 

The EOCC established a procedure to periodically inspect patient care 

equipment and furniture for compromised surfaces as a component of 

EOC rounds on June 30, 2008. Damaged equipment or furniture will be 

repaired or replaced as identified. The EOCC will re-educate patient care 

VA Office of Inspector General 27 
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri 

staff to report and remove from patient use any damaged equipment and 

furniture by August 1, 2008. 

Nurse managers (NM) and ACN will inspect all storage areas to identify 

locations where clean and dirty items may be stored together. Each 

identified location will be designated as clean or dirty with appropriate 

removal of items, signage and education to the area’s staff by 

August 30, 2008. 

The EOC rounds checklist will be modified to include checking bathroom 

pull cords, overbed light pull cords, room temperature of medication and 

supply rooms, inspection of patient care equipment and furniture for 

compromised surfaces, and appropriate storage of clean and dirty patient 

care items for 6 months beginning July 2008. 

Recommendation 11. We recommended that the VISN Director ensure 

that the Medical Center Director requires that safety vulnerabilities be 

corrected. 

Concur Target Date: December 31, 2008 

Engineering staff will replace ceiling tiles and grids in the day rooms of 

locked psychiatric units with a solid ceiling by October 30, 2008. Ceiling 

panels in main hallways of locked psychiatric units will have plastic tabs 

installed to prevent access by October 30, 2008. Day room ceiling and 

hallway ceiling tiles have been placed on MH EOC checklist action plan on 

May 21, 2008. 

Engineering staff will replace the shower control fixture in the women’s 

shower area on one of the locked psychiatric units with an institutional 

fixture by October 30, 2008. Shower control fixture has been placed on 

the MH EOC checklist on May 21, 2008. Until fixtures are replaced, the 

current practice of female nursing staff accompanying female patients 

while in the women’s shower area will continue. 

Engineering staff will replace the nursing station door on a locked 

psychiatric unit with a Dutch door to reduce the risk of allowing 

unauthorized entry to the area by October 30, 2008. The nurse’s station 

door has been placed on the MH EOC checklist on May 21, 2008. 

The EOC rounds checklist will be modified to include unsecured sharps, 

unsecured medication, unsecured cleaning products, obstructed valves 

and panels, oxygen storage, and legibility and accuracy of crash cart lock 

number on checklist for 6 months beginning July 2008. 

NMs and ACNs for each patient care area will eliminate the storage of 

needles and hemostats in unlocked carts. Medication and supply rooms 

will be reconfigured to all for appropriate storage and access to needles 

VA Office of Inspector General 28 
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri 

and hemostats. The ADPNS and ACNs will implement a daily check for 

unsecured sharps beginning July 1, 2008. 

The ACNs, NMs, and supervisors from Environmental Management 

Service (EMS) will re-educate nursing and EMS staff on the appropriate 

storage of cleaning products by July 30, 2008. The ACNs and NMs will 

re-educate staff and reinforce the procedures for the storage and security 

of medications by July 30, 2008. Engineering staff repaired the lock on 

the medical unit at JC division on May 9, 2008. 

NMs and ACNs inspected all storage areas where access to valves and 

panels were obstructed and items stored on the floor on July 1, 2008. 

Items were relocated and storage removed from the floor and placed on 

risers. Signage will be placed to remind staff not to obstruct access by 

July 30, 2008. 

The Chief of Logistics and the Safety Officer will revise the procedure for 

oxygen storage to improve the identification of tanks as full or empty by 

July 30, 2008. The Chief of Logistics and the Safety Officer will educate 

staff on the revised procedure by August 30, 2008. 

The Chief of QM will revise the MCM 11-13 “Emergency Resuscitation 

(Code K)” to reflect a change in the crash cart checklist and frequency 

from each shift to daily to align with medical center wide deployment of 

new defibrillators/Automated External Defibrillators by July 30, 2008. A 

reminder will be provided to patient care staff on the importance of 

accurate and legible transcription of lock numbers by July 30, 2008. 

Engineering staff will turn off the water to showers in all the combined 

shower rooms on the locked geriatric psychiatric unit by July 15, 2008. 

Engineering staff will seek a solution to the floor drain’s inability to handle 

the volume of water. The issue was identified when the unit was 

reopened after renovation. Since the safety risk was identified, the nursing 

staff have not been using these showers for patient care. The unit’s 

shower room is being utilized for patients. 

Recommendation 12. We recommended that the VISN Director ensure 

that the Medical Center Director requires that identified patient privacy 

vulnerabilities be corrected. 

Concur Target Date: July 30, 2008 

The ACOS and ACN for Primary Care reviewed each clinic site for patient 

privacy vulnerabilities on June 30, 2008. Patient sensitive information has 

been removed from routing sheets. Routing sheets are handed to the 

provider. Mailboxes in staff only areas have been placed for each 

provider to receive telephone messages from patients, which were 

previously placed in a holding device on provider’s door. 

VA Office of Inspector General 29 
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri 

ADPNS and ACNs will eliminate the clipboards with patient information at 

the patients’ bedside by July 30, 2008. The patient flow sheets will be 

stored at the nurse’s station. 

NMs and ACNs will remind and re-educate staff on appropriate handling of 

patient sensitive information by July 30, 2008. 

Engineering staff relocated the white marker board in the nurse’s station 

so that it is not viewable from the hallway on May 15, 2008. 

Recommendation 13. We recommended that the VISN Director ensure 

that the Medical Center Director requires an evaluation of inpatient mental 

health overflow, proper unit designation, and environmental planning to 

assure patient safety. 

Concur Target Date: July 30, 2008 

The ACOS and ACN will evaluate the overflow location within MH for the 

appropriate designation, environment, and staff competencies to assure 

patient safety by July 30, 2008. 

Recommendation 14. We recommended that the VISN Director ensure 

that the Medical Center Director requires that CS inspections are 

completed in accordance with VHA policy. 

Concur Target Date: December 31, 2008 

The CS Coordinator modified the CS Inspection tracking sheet to include 

the date each inspector plans to complete his/her inspections each month 

on May 16, 2008. The CS Coordinator modified the oversight procedure 

with the inspector to validate completion of all monthly inspections. This 

was implemented May 16, 2008. 

Recommendation 15. We recommended that the VISN Director ensure 

that the Medical Center Director corrects all identified EOC findings within 

the pharmacy at the JB division. 

Concur Target Date: December 31, 2008 

Engineering staff replaced the soiled ceiling tiles and sealed ceiling 

penetrations in the pharmacy at the JB division on June 6, 2008. All 

ceiling vents and the identified unit were cleaned and repaired on 

June 6, 2008. Engineering staff will develop a project to replace the 

flooring by December 31, 2008. 

Recommendation 16. We recommended that the VISN Director ensure 

that the Medical Center Director corrects the identified privacy concerns at 

the JB division. 

VA Office of Inspector General 30 
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri 

Concur Target Date: December 31, 2008 

To address the privacy concerns at the JB division pharmacy, the 

pharmacy manager removed a portion of the seating units to increase the 

distance between the patients waiting for the pharmacist and those being 

counseled by the pharmacist on June 1, 2008. The medical center’s 

Privacy Officer will complete a review of the area and make 

recommendation for additional actions to address privacy concerns by 

July 30, 2008. Engineering staff will evaluate the space for reconfiguration 

by December 31, 2008. 

Recommendation 17. We recommended that the VISN Director ensure 

that the Medical Center Director complies with VHA employment 

screening requirements. 

Concur Target Date: September 15, 2008 

The Chief of HR will initiate and complete background investigations on 

the physicians identified by the inspector by August 15, 2008. The Chief 

of HR will review and revise the HR “Standard Operating Procedure on 

Background Investigation” to include the appropriate filing of documents 

when an employee moves from a staff position to a without compensation 

or fee basis position by August 30, 2008. HR staff will be educated on the 

revised procedure by September 15. 2008. 

Recommendation 18. We recommended that the VISN Director ensure 

that the Medical Center Director requires that CPR training be 

documented in the electronic training record, in accordance with medical 

center policy. 

Concur Target Date: July 30, 2008 

The Chief of HR, Credentialing Coordinator, and Chief of QM reviewed 

and revised the process for documentation of CPR training for LIPs. CPR 

training for LIPs will be entered and tracked in the medical center’s 

privilege database. The Chief of QM will revise MCM 11-46 “Staff Training 

in Cardiopulmonary Resuscitation and Advance Cardiac Life Support” to 

reflect the change in the documentation process for CPR training for LIPs 

by July 30, 2008. Please see Recommendation 2 for related actions. 

Recommendation 19. We recommended that the VISN Director ensure 

that the Medical Center Director requires that all providers privileged to 

administer moderate sedation have documentation of current training in 

airway management and cardiac arrhythmias. 

Concur Target Date: July 30, 2008 

VA Office of Inspector General 31 
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri 

The service chiefs and QM completed a review of medical center 

privileges forms during the 2nd quarter of FY 2008. The sedation privilege 

description was revised to clarify the training required for the privilege. The 

medical center Director approved the revised privilege forms on 

March 2, 2008. The Credentialing Coordinator generated a list of 

providers with sedation privileges on May 30, 2008. The AO/BM will 

review each provider’s file for evidence of training in airway management 

and cardiac arrhythmias by July 30, 2008. Providers without evidence of 

training in airway management and cardiac arrhythmias will be requested 

via letter to provide evidence of training within 30 days. The Chief of Staff 

will be notified of providers who fail to comply. Action will be taken to 

suspend privileges for sedation and invasive procedures until evidence of 

training is provided. The Chief of QM will educate service chiefs on 

documentation requirements for granting privileges by July 30, 2008. 

Initial privileges and reappointment privileges will not be recommended by 

the Professional Standards Board unless evidence of training is present 

and in the credentialing packet beginning July 15, 2008. 

Recommendation 20. We recommended that the VISN Director ensure 

that the Medical Center Director requires that providers who administer 

moderate sedation obtain privileges in accordance with VHA policy. 

Concur Target Date: July 30, 2008 

The Credentialing Coordinator and Chief of QM will review the list of all 

providers with invasive procedure privileges to identify those who did not 

request the sedation privilege. The providers will be notified via letter and 

asked to request the sedation privileges by July 30, 2008. Those 

providers choosing not to request the sedation privilege will be reviewed 

by the service chief to ensure that the provider does not utilize sedation in 

practice. 

VA Office of Inspector General 32 
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri

Appendix C

OIG Contact and Staff Acknowledgments 

Contact Verena Briley-Hudson, MN, RN, Director 

Chicago Office of Healthcare Inspections 

(708) 202-2672 

Contributors Wachita Haywood, MS, RN, Associate Director 

Jennifer Reed, RN, Health Systems Specialist, Team Leader 

Lisa Barnes, MSW, Health Systems Specialist 

Paula Chapman, CTRS, Health Systems Specialist 

Roberta Thompson, MSW, Health Systems Specialist 

James Werner, Special Agent, Office of Investigations 

Judy Brown, Program Support Assistant 

VA Office of Inspector General 33 
Combined Assessment Program Review of the St. Louis VA Medical Center, St. Louis, Missouri 

Appendix D 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, Veterans Integrated Service Network 15 (10N15) 

Director, St. Louis VA Medical Center (657/00) 

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, Richard Durbin, Claire McCaskill, Barack Obama 

U.S. House of Representatives: Todd Akin, Russ Carnahan, William “Lacy” Clay, Jr., 

Jerry Costello, Jo Ann Emerson, Phil Hare, Kenny Hulshof, Ray LaHood, 

John Shimkus 

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

VA Office of Inspector General 34