Department of Veterans Affairs

Office of Inspector General

Office of Healthcare Inspections

Report No. 07-03176-17

Combined Assessment Program 

Review of the 

Togus VA Medical Center 

Augusta, Maine 

November 3, 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 Togus VA Medical Center, Augusta, Maine 

Table of Contents 

Page 

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

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

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

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

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

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

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

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

Pharmacy Operations........................................................................................ 6 

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

Emergency Department/Urgent Care Clinic ...................................................... 9 

Coordination of Care ......................................................................................... 10 

Medication Management ................................................................................... 11 

Review Activities Without Recommendations ......................................................... 12 

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

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

Appendixes

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

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

C. OIG Contact and Staff Acknowledgments ......................................................... 21 

D. Report Distribution............................................................................................. 22 

VA Office of Inspector General 
Combined Assessment Program Review of the Togus VA Medical Center, Augusta, Maine 

Executive Summary 

Introduction During the week of September 8–12, 2008, the OIG 

conducted a Combined Assessment Program (CAP) review 

of the Togus VA Medical Center (the medical center), 

Augusta, ME. 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 for 

92 medical center employees. The medical center is part of 

Veterans Integrated Service Network (VISN) 1. 

Results of the 

Review 

This CAP review covered eight operational activities. We 

also followed up on one review area from the July 2005 CAP 

review. We identified the following organizational strengths 

and reported accomplishments: 

• Improved access to outpatient care. 

• Improved access to inpatient care. 

• Recipient of the 2008 VISN 1 award for the greatest 

improvement in employee satisfaction. 

We made recommendations in six of the activities reviewed. 

For these activities, medical center managers needed to: 

• Analyze provider performance data as part of the 

reprivileging process. 

• Ensure that Professional Standards Board (PSB) minutes 

reflect all pertinent activity and are approved by the 

Director. 

• Ensure that Peer Review Committee (PRC) minutes 

reflect all pertinent peer review activity and are 

distributed and approved by the committee. 

• Ensure that the PRC reviews mortality cases that meet 

criteria and reports peer review activity quarterly to the 

Medical Executive Committee (MEC). 

• Ensure that clinical managers monitor the use of reversal 

agents for moderate sedation. 

• Validate the security of blank prescription pads. 

• Monitor and record temperatures for medication and 

patient nutrition refrigerators daily. 

VA Office of Inspector General i
Combined Assessment Program Review of the Togus VA Medical Center, Augusta, Maine 

• Improve security in the Emergency Department (ED) and 

in the ED triage area. 

• Ensure that discharge summaries are completed, 

discharge instructions are consistent with discharge 

summaries, and patients receive discharge instructions. 

• Document pain reassessments within the appropriate 

timeframes and document the actions taken if 

medications are ineffective. 

• Ensure that nurses scan patients’ wristbands prior to 

medication administration. 

The medical center complied with selected standards in the 

following two activities: 

• Staffing. 

• Survey of Healthcare Experiences of Patients (SHEP). 

This report was prepared under the direction of 

Katherine Owens, Director, Bedford Office of Healthcare 

Inspections. 

Comments The VISN and Medical Center Directors agreed with the CAP 

review findings and recommendations and provided 

acceptable improvement plans. (See Appendixes A and B, 

pages 15–20 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 Togus VA Medical Center, Augusta, Maine 

Introduction 

Profile Organization. The medical center is located in Augusta, 

ME, and provides a broad range of inpatient and outpatient 

health care services. It also provides outpatient services at 

six community based outpatient clinics (CBOCs) in Bangor, 

Calais, Caribou, Lincoln, Rumford, and Saco, ME, and has a 

mental health (MH) clinic in Portland, ME. The medical 

center is part of VISN 1 and serves a veteran population of 

approximately of 145,000. 

Programs. The medical center is a primary and secondary 

health care facility and provides comprehensive health care 

services in medicine, surgery, psychiatry, and long-term 

care. 

Affiliations and Research. The medical center is affiliated 

with the Massachusetts Eye and Ear Infirmary in Boston, 

MA, and provides training for residents in ophthalmology. It 

also serves as a training site for students in psychiatry, 

clinical psychology, dentistry, and nursing. The medical 

center is in the process of developing a full-time research 

program. 

Resources. In fiscal year (FY) 2007, the medical center’s 

medical care budget totaled approximately $145 million. For 

FY 2008, the medical care budget was approximately 

$164 million. FY 2008 staffing was 1,162 full-time employee 

equivalents (FTE), including 80 physician and 370 nursing 

FTE. 

Workload. During FY 2007, the medical center treated 

approximately 38,000 unique patients and provided inpatient 

care to more than 1,300 patients. It had 67 operating 

hospital beds with an average daily census (ADC) of 44 and 

100 operating community living center (CLC)1

 beds with an 

ADC of 61. Outpatient workload for FY 2007 totaled over 

332,000 visits. 

Objectives and 

Scope 

Objectives. CAP reviews are one element of the OIG’s 

efforts to ensure that our Nation’s veterans receive high 

quality VA health care services. The objectives of the CAP 

review are to: 

 

1

 A CLC (formerly called a nursing home care unit) provides compassionate, person-centered care in a safe and 

homelike environment to eligible veterans who require a nursing home level of care. 

VA Office of Inspector General 1 
Combined Assessment Program Review of the Togus VA Medical Center, Augusta, Maine 

• 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.

• ED/Urgent Care Clinic (ED/UCC).

• Environment of Care (EOC).

• Medication Management.

• Pharmacy Operations.

• QM Program.

• SHEP.

• Staffing.

The review covered medical center operations for FY 2007 

and quarters 1 and 2 of FY 2008 and was done in 

accordance with OIG standard operating procedures for 

CAP reviews. We also followed up on recommendations 

from the prior CAP review of the medical center (Combined 

Assessment Program Review of the Togus VA Medical 

Center, Togus, Maine, Report No. 05-01608-85, 

February 8, 2006). In that report, we identified improvement 

opportunities in radiology timeliness. During the follow-up 

review, we found sufficient evidence that managers had 

implemented appropriate actions to address the identified 

deficiencies, and we consider those issues closed. 

VA Office of Inspector General 2 
Combined Assessment Program Review of the Togus VA Medical Center, Augusta, Maine 

During this review, we presented fraud and integrity 

awareness briefings for 92 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 made 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 

Improved Access to 

Outpatient Care 

The medical center initiated processes that increased 

access to outpatient care by improving the use of medical 

center and community resources for specialty clinic 

appointments, enhancing clinic staffing, and educating staff 

about appointment scheduling. As a result, between 

October 2007 and September 2008, the number of patients 

waiting over 30 days for clinic appointments decreased from 

more than 2,600 to less than 200. 

Improved Access to 

Inpatient Care 

In February 2007, the medical center’s average length of 

stay for acute medicine beds was over 11 days. The 

medical center implemented strategies that improved 

discharge planning and helped reduce delays in patient 

discharges. These efforts improved access to inpatient care, 

and at the time of our CAP review, the average length of 

stay on acute medicine had been reduced to approximately 

5.4 days. 

Employee 

Satisfaction Award 

Medical center senior managers implemented strategies to 

improve communication between leadership and employees 

and between leadership and patients. As a result, the 

medical center’s All Employee Survey results improved, and 

the medical center received the 2008 VISN 1 “Greatest 

Improvement in Employee Satisfaction” award. 

VA Office of Inspector General 3 
Combined Assessment Program Review of the Togus VA Medical Center, Augusta, Maine 

Results 

Review Activities With Recommendations 

Quality 

Management 

Program 

The purpose of this review was to evaluate whether the 

medical center had a comprehensive QM program designed 

to monitor patient care quality and whether senior managers 

actively supported the program’s activities. We evaluated 

policies, performance improvement (PI) data, and other 

relevant documents, and we interviewed appropriate senior 

managers and the QM Coordinator. The medical center’s 

QM program was generally effective, and senior managers 

supported the program through participation in and 

evaluation of PI initiatives and through allocation of 

resources to the program. However, we identified areas that 

needed improvement. 

Provider Performance Monitoring. Veterans Health 

Administration (VHA) regulations2

 and The Joint 

Commission (JC)3 require that clinical managers develop 

plans for continuous performance monitoring for the medical 

staff. According to the requirements, performance data 

should be ongoing, include indicators for continuing 

qualifications and competencies, and be reviewed and 

considered during the reprivileging process.4 At the time of 

our visit, clinical leaders had completed the credentialing and 

privileging (C&P) training modules, and plans for ongoing 

physician competency monitoring had been developed. We 

reviewed C&P folders and corresponding PI data for 

18 providers reprivileged in the past 12 months. We found 

that 11 of the 18 providers had inadequate data for the 

privileges granted. 

Professional Standards Board Minutes. We found that there 

were no approved PSB minutes available from 

April–August 2008. The role of the PSB is to review relevant 

provider information, document discussions, and make 

recommendations associated with the requested clinical 

privileges. The outcomes of the discussions are to be 

recorded in the PSB minutes and then reviewed and 

approved by the Chair of the PSB, the Chief of Staff, and the 

medical center’s Director. VHA regulations5

 delineate that 

 

2

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

 The Joint Commission, Comprehensive Accreditation Manual for Hospitals, January 2007, MS.4.40. 4

 The process of evaluating professional credentials and clinical competencies of practitioners who hold clinical 

privileges at the facility. 

5

 VHA Handbook 1100.19. 

VA Office of Inspector General 4 
Combined Assessment Program Review of the Togus VA Medical Center, Augusta, Maine 

facility Directors have ultimate responsibility for C&P. The 

medical center’s Director should have the benefit of 

reviewing PSB minutes prior to approving clinical privileges. 

Peer Review. VHA regulations6 require that the PRC 

document peer review activity. The documentation (typically 

in PRC minutes) should reflect the rationale for changes in 

levels of care, indicate that providers with peer reviews 

designated at levels 2 and 37 were invited to respond to 

PRC findings, and show that identified improvement actions 

were implemented. 

The PRC met at least quarterly, as required; however, PRC 

minutes did not consistently reflect the required aspects of 

the peer review process. We also found that PRC minutes 

were not consistently distributed for review and approval. 

Additionally, we found that the PRC did not review 

mortalities that met criteria for peer review, as required. 

Mortalities were instead reviewed as part of the morbidity 

and mortality process. Also, the PRC did not report peer 

review activity quarterly to the MEC. 

Moderate Sedation. While clinical managers monitored 

outcomes of moderate sedation, we did not find evidence 

that they monitored the use of reversal agents,8 as required 

by VHA regulations.9

Recommendation 1 We recommended that the VISN Director ensure that the 

Medical Center Director requires that provider PI data are 

collected and analyzed as part of the reprivileging process 

for all providers. 

We recommended that the VISN Director ensure that the 

Medical Center Director requires that PSB minutes reflect all 

required elements and that they are forwarded to the 

Director for review and approval. 

Recommendation 2 

We recommended that the VISN Director ensure that the 

Medical Center Director requires that PRC minutes reflect 

the required elements of the peer review process and that 

the minutes are distributed for review and approval. 

Recommendation 3 

 

6

 VHA Directive 2008-004, Peer Review for Quality Management, January 28, 2008. 7

 Level 2 indicates that most experienced, competent practitioners might have managed the case differently. Level 3 

indicates that most experienced, competent practitioners would have managed the case differently. 8

 Reversal agents are medications used to counteract the effects of sedation. 9

 VHA Directive 2006-023, Moderate Sedation by Non-Anesthesia Providers, May 1, 2006. 

VA Office of Inspector General 5 
Combined Assessment Program Review of the Togus VA Medical Center, Augusta, Maine 

Recommendation 4 We recommended that the VISN Director ensure that the 

Medical Center Director requires that the PRC review 

mortalities that meet criteria and report peer review activity 

quarterly to the MEC. 

Recommendation 5 We recommended that the VISN Director ensure that the 

Medical Center Director requires that clinical managers 

include the use of reversal agents when monitoring 

moderate sedation outcomes. 

The VISN and Medical Center Directors agreed with the 

findings and recommendations. They reported that clinical 

managers initiated a revision of the privileging forms and the 

reporting format to extract provider PI data. The template for 

PSB minutes has been revised to include all required 

elements, and the minutes will be forwarded to the Director 

for review. They also reported that PRC minutes will include 

all required elements and be distributed timely. The PRC 

will review all mortalities that meet criteria and report peer 

review activity quarterly to the MEC. Additionally, clinical 

managers revised the moderate sedation monitoring form to 

include the use of reversal agents. The implementation 

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

actions until they are completed. 

Pharmacy 

Operations 

The purposes of this review were to evaluate whether VA 

health care facilities had adequate controls to ensure the 

security and proper management of controlled substances 

(CS) and pharmacies’ internal physical environments and 

whether clinical managers had processes to monitor 

inpatient and outpatient medication use to avoid 

polypharmacy in vulnerable populations, such as the elderly 

and MH patients. 

Pharmacy Controls. We reviewed VHA regulations10

governing pharmacy and CS security, and we assessed 

whether the medical center’s policies and processes were 

consistent with VHA regulations. We reviewed the CS 

inspection program and inspected inpatient and outpatient 

pharmacies for security, EOC, and infection control issues. 

In addition, we interviewed CS inspectors and appropriate 

Pharmacy Service and Police and Security Service 

managers. Our review showed that the medical center’s CS 

 

10 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. 

VA Office of Inspector General 6 
Combined Assessment Program Review of the Togus VA Medical Center, Augusta, Maine 

inspection program was well organized and managed. 

However, we found that CS inspectors did not validate 

pharmacy controls over blank prescription pads, as required 

by VHA regulations.11 

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 

treat adverse drug reactions.12 Some literature suggests 

that elderly patients and MH patients are among the most 

vulnerable populations for polypharmacy.13

We interviewed pharmacy clinical managers to determine 

the medical center’s efforts to monitor and avoid 

inappropriate polypharmacy. Clinical pharmacists identified 

patients who were prescribed multiple medications, reviewed 

the patients’ medication regimens to avoid complications 

related to polypharmacy, and advised providers regarding 

potential polypharmacy complications when appropriate. 

Recommendation 6 We recommended that the VISN Director ensure that the 

Medical Center Director requires that CS inspectors validate 

the security of blank prescription pads stored in the 

pharmacies. 

The VISN and Medical Center Directors agreed with the 

finding and recommendation. They reported that managers 

added the validation of blank prescription pad security to the 

CS inspectors’ checklist. Inspectors will begin using the 

revised checklist the week of October 13, 2008. The 

implementation plan is acceptable, and we will follow up on 

the planned action until it is completed. 

 

11 VHA Handbook 1108.2. 

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

December 2004. 

13 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 7 
Combined Assessment Program Review of the Togus VA Medical Center, Augusta, Maine 

Environment of 

Care

The purpose of this review was to determine whether the 

medical center maintained a safe and clean health care 

environment. VHA regulations require that health care 

facilities provide clean and safe environments in all patient 

care areas and establish comprehensive EOC programs that 

fully meet National Center for Patient Safety, Occupational 

Safety and Health Administration, and JC standards. We 

inspected the following areas: (a) two CLCs (b) one medical 

unit, (c) one surgical unit, (d) the same day surgery area, 

(e) the outpatient dialysis unit, (f) the specialty care unit, 

(g) acute MH, (h) the dental clinic, (i) primary care, (j) the 

inpatient and outpatient pharmacies, (k) the women’s clinic, 

and (l) the Saco CBOC. 

The areas we inspected were clean and well maintained, 

and nurse managers expressed satisfaction with the 

housekeeping staff assigned to their units. Additionally, we 

inspected the acute inpatient MH unit to determine if 

managers identified environmental hazards that potentially 

posed threats to patients and to ensure that staff 

received specialized training. The medical center provided 

documentation of risk assessment and abatement tracking of 

safety issues previously identified on the MH unit, and we 

found that suicide risk training was completed. However, we 

identified one area that needed improvement. 

Safety. We found that temperature logs for two patient 

nutrition refrigerators and the medication refrigerator on one 

CLC showed that temperatures were not monitored and 

recorded on a daily basis, as required by medical center 

policy.14 Appropriate temperature controls ensure the safety 

of food items and maintain the efficacy of medications.

Recommendation 7 We recommended that the VISN Director ensure that the 

Medical Center Director requires nursing personnel to 

monitor and record temperatures in medication and nutrition 

refrigerators daily. 

The VISN and Medical Center Directors agreed with the 

finding and recommendation. They reported that the 

Nursing Procedure Committee drafted a procedure specific 

to nutrition and medication refrigerator temperature 

monitoring. Nurse managers will monitor compliance with 

 

14 Togus VA Medical Center Nursing Procedure 118P-03-1, Digital Thermometer Recording, March 3, 2006. 

VA Office of Inspector General 8 
Combined Assessment Program Review of the Togus VA Medical Center, Augusta, Maine 

the procedure. The implementation plan is acceptable, and 

we will follow up on the planned action until it is completed. 

Emergency 

Department/Urgent 

Care Clinic

The purpose of this review was to evaluate selected aspects 

of clinical services, staff competencies, and operations in 

VHA ED/UCCs. We also determined whether the physical 

environment was clean and safe and whether managers 

maintained equipment appropriately. The medical center did 

not have a UCC but did have an ED that operated 7 days a 

week, 24 hours a day. 

We interviewed ED managers and the clinicians involved in 

managing patient inter-facility transfers. We reviewed 

policies and other pertinent documents, including equipment 

maintenance records. Additionally, we reviewed medical 

records of patients who had consults to other services and 

who were transferred from the ED to other medical facilities. 

Our review showed that consults, transfers, and staff 

competencies were appropriate. We found that the area 

was clean and that managers appropriately maintained 

equipment. However, we identified one area that needed 

improvement. 

Security. The JC requires that the medical center identify 

and manage its security risks.15 At the time of our CAP 

review, access to the ED was unrestricted because entry 

doors to the area could not be locked. ED managers 

reported that they had ordered keypad locks but that the 

locks had not yet arrived. Additionally, the ED triage area 

was separated from the patient waiting area by a low counter 

that could easily be breached, and there was no duress 

alarm available for employees to summon help if needed. 

Triage area employees recently expressed concerns to 

management about their safety, particularly when patients 

waiting for ED services become agitated or aggressive. 

Recommendation 8 We recommended that the VISN Director ensure that the 

Medical Center Director requires the installation of locks on 

ED doors and the improvement of security in the triage area. 

The VISN and Medical Center Directors agreed with the 

findings and recommendation. They reported that Facility 

Management Service managers contracted for the 

installation of locks on the ED entry doors and completed 

construction of a “safe” room in the ED for monitoring 

 

15 The Joint Commission, Comprehensive Accreditation Manual for Hospitals, September 2007, EC.2.10. 

VA Office of Inspector General 9 
Combined Assessment Program Review of the Togus VA Medical Center, Augusta, Maine 

agitated patients. They also reported that plans are in place 

to add a duress alarm in the triage workstation area. The 

implementation plans are acceptable, and we will follow up 

on the planned actions until they are completed. 

Coordination of 

Care 

The purpose of this review was to evaluate whether VHA 

facilities had adequate processes to ensure coordination of 

care across the continuum of patient services. We reviewed 

three aspects of care: (a) patient consults, (b) patient 

intra-facility transfers, and (c) patient discharges. We found 

that providers managed patient consults and 

intra-facility transfers appropriately. However we identified 

one area that needed improvement. 

Patient Discharges. We reviewed medical record 

documentation for 12 patients discharged from inpatient 

care, and as part of the ED review, 2 MH patients 

discharged from the ED. We found documentation 

deficiencies in nine of the records reviewed. One inpatient 

record had no discharge summary, and inconsistencies 

between discharge summaries and patient discharge 

instructions existed in five other inpatient records. VHA 

regulations16 require that discharge summaries be 

completed prior to discharge and that specific information be 

included in discharge summaries and instructions. 

Additionally, three records did not have documentation to 

support that the patients received discharge instructions at 

the time of discharge from the medical center (one from 

inpatient care and the two from the ED). Medical center 

policy17 requires that clinicians provide written discharge 

instructions to all patients. 

Recommendation 9 We recommended that the VISN Director ensure that the 

Medical Center Director requires that discharge summaries 

are completed, that discharge instructions are consistent 

with discharge summaries, and that patients receive written 

discharge instructions. 

The VISN and Medical Center Directors agreed with the 

findings and recommendation. They reported that the Chief 

of Staff will send a memorandum re-educating providers 

about the facility’s requirements. ED clinical managers will 

research computer software applicable to the ED to provide 

standardized discharge instruction documentation. The 

 

16 VHA Handbook 1907.01, Health Information Management and Health Records, August 25, 2006. 17 Togus VA Medical Center Circular 00-03-81(11), Admission and Discharge Planning, September 2003. 

VA Office of Inspector General 10 
Combined Assessment Program Review of the Togus VA Medical Center, Augusta, Maine 

implementation plans are acceptable, and we will follow up 

on the planned actions until they are completed. 

Medication 

Management 

The purpose of this review was to evaluate whether VHA 

facilities had adequate medication management processes 

to ensure safe ordering, dispensing, administering, and 

monitoring of medications. We reviewed medication 

management processes on inpatient units, and we 

interviewed nurse managers and other nursing staff. 

Additionally, we observed nurses administering medications, 

and we asked patients if nurses scanned their wristbands 

prior to administering their medications. 

We found adequate management of medications brought 

into the facility by patients or their families. Additionally, we 

found that the processes for reconciling CS discrepancies at 

the unit level were adequate. However, we identified two 

areas that needed improvement. 

Pain Medication Effectiveness. VHA regulations18 and the 

JC19 require that clinicians monitor PRN20 medications for 

effectiveness. Additionally, medical center policy governing 

pain management requires that pain reassessments occur 

30–60 minutes after each pain management intervention.21

We reviewed 124 administered doses of PRN pain 

medications and found that pain reassessments were not 

consistently documented within the required timeframe. 

Additionally, we found that clinicians did not consistently 

document appropriate actions taken if the pain medications 

proved ineffective. 

Medication Administration. The medical center’s Bar Code 

Medication Administration (BCMA) policy requires that 

nurses scan patients’ wristbands prior to medication 

administration.22 This practice correctly identifies patients 

and reduces medication errors. We found that staff scanned 

patient wristbands prior to medication administration on all 

units except one. On that unit, we observed that a nurse did 

not scan the wristband of a patient. The nurse explained 

that the wristband was not scanned because the patient was 

in isolation. However, BCMA policy outlines the process to 

 

18 VHA Directive 2003-021, Pain Management, May 2, 2003. 

19 The Joint Commission, Comprehensive Accreditation Manual for Hospitals, January 2007, MM-15. 20 PRN is a Latin abbreviation [L pro re nata] meaning as needed or as the circumstances require. 21 Togus VA Medical Center Circular 00-05-08(11), Pain Management, February 15, 2005. 22 Togus VA Medical Center Nursing Procedure 118P-08-4, Bar Code Medication Administration (BCMA) 

Procedure, March 7, 2008, p. 4. 

VA Office of Inspector General 11 
Combined Assessment Program Review of the Togus VA Medical Center, Augusta, Maine 

use when scanning wristbands of patients who are in 

isolation.23 In addition, another patient stated that nurses 

did not consistently scan his wristband prior to each 

medication administration. The nurse manager 

acknowledged that scanning patients’ wristbands was not 

consistently performed. 

Recommendation 10 We recommended that the VISN Director ensure that the 

Medical Center Director requires documentation of pain 

reassessments within appropriate timeframes and the 

documentation of actions taken when medications are 

ineffective. 

Recommendation 11 We recommended that the VISN Director ensure that the 

Medical Center Director requires that nurses scan all 

patients’ wristbands prior to medication administration and 

that compliance with this requirement is monitored. 

The VISN and Medical Center Directors agreed with the 

findings and recommendations. They reported that the 

Nursing Procedure Committee is revising the medical 

center’s current policy and expects approval in 

November 2008. They also reported that the PRN 

effectiveness report is being run at the end of each shift and 

is reviewed it for appropriate documentation. Additionally, 

nurse managers anticipate the availability of the BCMA 

software enhancement that will report and track failures to 

scan wristbands by the end of December 2008. In the 

meantime, the BCMA Coordinator is conducting random 

observations to monitor compliance. The implementation 

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

actions until they are completed. 

Review Activities Without Recommendations 

Staffing The purpose of this review was to evaluate whether VHA 

facilities developed comprehensive nurse staffing guidelines 

and whether the guidelines were met. We reviewed nurse 

staffing documents for all inpatient units, including the 

intensive care unit, and interviewed nurse managers. We 

found the staffing methodology to be appropriate. We made 

no recommendations. 

 

23 Ibid., p. 5. 

VA Office of Inspector General 12 
Combined Assessment Program Review of the Togus VA Medical Center, Augusta, Maine 

Survey of 

Healthcare 

Experiences of 

Patients 

The purpose of this review was to assess the extent that 

VHA medical facilities use quarterly or semi-annual SHEP 

results to improve patient care 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 goals for patients reporting overall 

satisfaction of “very good” or “excellent” at 76 percent for 

inpatients and 77 percent for outpatients. 

We reviewed survey results for quarter 3 of FY 2006 through 

quarter 2 of FY 2008. The medical center’s inpatient results 

met or exceeded the target in 7 of the 8 quarters reviewed. 

The medical center’s outpatient results exceeded the target 

in all eight quarters reviewed. Findings are displayed in the 

graphs below and on the next page. 

60

65

70

75

80

85

90

95

100

Qtr 3 (FY 06) 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)

Quarter Reported

Percent Reporting Overall Quality as Very Good or Excellent

Facility

VISN

National

TOGUS VA MEDICAL CENTER

INPATIENT OVERALL QUALITY

BY QUARTER

Meets 

Target

Figure 1:

VA Office of Inspector General 13 
Combined Assessment Program Review of the Togus VA Medical Center, Augusta, Maine 

60

65

70

75

80

85

90

95

100

Qtr 3 (FY 06) 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)

Quarter Reported

Percent Reporting Overall Quality as Very Good or Excellent

Facility

VISN

National

TOGUS VA MEDICAL CENTER

OUTPATIENT OVERALL QUALITY

BY QUARTER

Figure 2:

Meets 

Target

Medical center managers analyzed their survey results, 

developed improvement strategies, and monitored the 

results of the action plans. Survey results and improvement 

strategies were disseminated throughout the organization. 

We made no recommendations. 

VA Office of Inspector General 14 
Combined Assessment Program Review of the Togus VA Medical Center, Augusta, Maine 

Appendix A 

VISN Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: October 9, 2008 

From: Director, VA New England Healthcare System (10N1) 

Subject: Combined Assessment Program Review of the Togus 

VA Medical Center, Augusta, Maine

To: Director, Bedford Office of Healthcare Inspections (54BN) 

Director, Management Review Service (10B5) 

I have reviewed the findings and Recommendations and concur. Our 

actions to the Recommendations are attached. For further information, 

please contact the VISN 1 QMO. 

 (original signed by:) 

MICHAEL MAYO-SMITH, MD, MPH 

VISN 1 Network Director 

VA Office of Inspector General 15 
Combined Assessment Program Review of the Togus VA Medical Center, Augusta, Maine 

Appendix B 

Medical Center Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: October 7, 2008 

From: Director, Togus VA Medical Center (402/00) 

Subject: Combined Assessment Program Review of the Togus 

VA Medical Center, Augusta, Maine

To: Director Bedford Office of Healthcare Inspections (54BN) 

Director, Management Review Service (10B5) 

We concur with the findings and the eleven recommendations presented 

in the Togus VA Medical Center OIG CAP Review. Comments to the 

report on the following pages comprise a brief implementation plan and 

target completion date to address each recommendation. 

The organization benefited from the thorough review of our operations, 

systems, and processes as well as from the inherent helpful, consultative 

nature of the team members interactions with staff. 

The goal to provide excellent quality of health care for the veterans of 

Maine is, of course, always in our sights as we dedicate our efforts and 

resources every day. 

Questions or further comments regarding this response can be directed to 

me with the anticipation of a complete and timely reply. Thank you. 

(original signed by:) 

Brian G. Stiller 

Director, Togus VA Medical Center 

 

VA Office of Inspector General 16 
Combined Assessment Program Review of the Togus VA Medical Center, Augusta, Maine 

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 provider PI data are 

collected and analyzed as part of the reprivileging process for all 

providers. 

Concur – Target Completion Date: December 31, 2008 

A revision of the privileging forms and the reporting format to extract PI 

data from various facility databases has been initiated by the COS Office. 

When rolled out to the Clinical Service Chiefs, the data will be utilized in 

the review and consideration for each individual during the reprivileging 

process. 

Recommendation 2. We recommended that the VISN Director ensure 

that the Medical Center Director requires that PSB minutes reflect all 

required elements and that they are forwarded to the Director for review 

and approval.

Concur – Completion Date: September 30, 2008 

Effective September 30, 2008, the template for PSB minutes has been 

changed to include all required elements. Minutes are forwarded to the 

Center Director for review and approval and to assist in the reprivileging 

decision. Request recommendation be closed. 

Recommendation 3. We recommended that the VISN Director ensure 

that the Medical Center Director requires that PRC minutes reflect the 

required elements of the peer review process and that the minutes are 

distributed for review and approval.

Concur – Target Completion Date: October 27, 2008 

The PRC Chair has directed the recorder to include the required elements 

of the peer review process in all subsequent minutes and electronically 

distribute them to members prior to each meeting. All FY 2008 meeting 

minutes have been distributed reviewed and approved by the PRC. The 

Peer Review Committee will formally address the recommendation at the 

VA Office of Inspector General 17 
Combined Assessment Program Review of the Togus VA Medical Center, Augusta, Maine 

October meeting to ensure members are made aware of their 

responsibility to respond if minutes are not provided accordingly. 

Recommendation 4. We recommended that the VISN Director ensure 

that the Medical Center Director requires that the PRC review mortalities 

that meet criteria and report peer review activity quarterly to the MEC.

Concur – Completion Date: August 1, 2008 

In accordance with VHA Directive 2008-004, Peer Review, all mortalities 

that meet criteria for peer review are now identified using the occurrence 

screen by the Quality Management Specialist and directed to the Peer 

Reviewer through the protected Peer Review notification process by the 

Quality Manager. Quarterly report of the Peer Review activity by the 

Chair, PRC has been added as a standard agenda item to the Clinical 

Executive Board. The first of these having been reported at the 

September 11, 2008 meeting. Request recommendation be closed. 

Recommendation 5. We recommended that the VISN Director ensure 

that the Medical Center Director requires that clinical managers include 

the use of reversal agents when monitoring moderate sedation outcomes.

Concur – Target Completion Date: December 1, 2008 

The form on which moderate sedation is documented has recently been 

modified to specifically include the use of a reversal agent. The Chief, 

Surgical Service, has put a process in place to receive and review the 

forms from the three services in which moderate sedation occurs. He will 

report the results to the Invasive Procedure Committee. 

Recommendation 6. We recommended that the VISN Director ensure 

that the Medical Center Director requires that CS inspectors validate the 

security of blank prescription pads stored in the pharmacies.

Concur – Target Completion Date: October 31, 2008 

The validation of the security of blank prescription pads has been added to 

the required elements for review on the CS inspector’s checklist. 

Utilization of the revised checklist by the inspectors will commence with 

inspections the week of October 13, 2008. The Controlled Substance 

Coordinator (CSC) will monitor the results and include any discrepancies 

in her report so appropriate investigation/actions can be taken. 

Recommendation 7. We recommended that the VISN Director ensure 

that the Medical Center Director requires nursing personnel to monitor and 

record temperatures in medication and nutrition refrigerators daily. 

Concur – Target Completion Date: November 28, 2008 

VA Office of Inspector General 18 
Combined Assessment Program Review of the Togus VA Medical Center, Augusta, Maine 

The Nurse Executive directed action to be taken. Nursing Procedure 

Committee has reviewed and drafted the facility Nursing Procedure 

118-08-13. Approval of draft is anticipated at the November 12th meeting. 

Specific documentation on a check sheet of the nutrition and medication 

refrigerators and action taken on any variation outside of range is now 

required. Once approved by the committee and circulated, the Nurse 

Managers will monitor the compliance and accountability. 

Recommendation 8. We recommended that the VISN Director ensure 

that the Medical Center Director requires the installation of locks on ED 

doors and the improvement of security in the triage area. 

Concur – Target Completion Date: November 28, 2008 

Chief, Facility Management Service, has placed the request for 

procurement and contracted out the installation of locks on entry doors to 

the area. A “safe” room has also recently been added in the ED to provide 

a safe environment for both staff and patient. In addition to the duress 

alarms in the nurse’s station and life support room, plans are in place for 

one to be installed in the triage work station area. 

Recommendation 9. We recommended that the VISN Director ensure 

that the Medical Center Director requires that discharge summaries are 

completed, that discharge instructions are consistent with discharge 

summaries, and that patients receive written discharge instructions.

Concur – Target Completion Date: October 31, 2008 for Action 1 and 

December 31, 2008 for Action 2 

Action 1 – The COS is sending a memorandum re-educating the clinical 

providers on the facility policy as stated above. 

Action 2 – The Chief, Medicine Service, and the ED Director are currently 

consulting colleagues and pursuing possible software applications for 

discharge instruction, e.g., Logicare, applicable to the ED to provide 

useful, standardized discharge instruction documentation. 

Recommendation 10. We recommended that the VISN Director ensure 

that the Medical Center Director requires the documentation of pain 

reassessments within appropriate timeframes and the documentation of 

actions taken when medications are ineffective.

Concur – Target Completion date: November 28, 2008 

The Nurse Executive directed action on this recommendation. The 

Nursing Procedure Committee researched references for guidance on 

more appropriate time frames. The current policy is being reworked with 

attention to the time range, anticipating a draft for approval at the 

VA Office of Inspector General 19 
Combined Assessment Program Review of the Togus VA Medical Center, Augusta, Maine 

November meeting. The prn effectiveness report is being run at the end 

of each nursing shift on all nursing units and reviewed for appropriate 

documentation. 

Recommendation 11. We recommended that the VISN Director ensure 

that the Medical Center Director requires that nurses scan all patients’ 

wristbands prior to medication administration and that compliance with this 

requirement is monitored. 

Concur – Target Completion Date: December 31, 2008 

The BCMA software enhancement, Managing Scanning Failures, is 

anticipated to be launched by the end of December, 2008. Reporting and 

tracking of failures to scan the wristband will be possible. Following the 

training of the BCMA Coordinator by Nov. 5, facility end user training will 

be scheduled. The BCMA Coordinator is conducting random observations 

to monitor the nursing staff compliance while passing medication, 

re-educating and reinforcing procedure with individuals as needed. Any 

issues with repeat non-compliance to procedure are brought to the 

supervisor’s attention for further action. 

VA Office of Inspector General 20 
Combined Assessment Program Review of the Togus VA Medical Center, Augusta, Maine 

Appendix C 

OIG Contact and Staff Acknowledgments 

Contact Katherine Owens, MSN, Director 

Bedford Office of Healthcare Inspections 

(603) 222-5871 

Contributors Annette Acosta, MN, Team Leader 

Nancy Albaladejo, MSN 

Kathy Gudgell, BSN, RN 

Jeanne Martin, Pharm.D. 

Timothy Bond, Office of Investigations 

VA Office of Inspector General 21 
Combined Assessment Program Review of the Togus VA Medical Center, Augusta, Maine

Appendix D 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VA New England Healthcare System (10N1) 

Director, Togus VA Medical Center (402/00) 

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: Susan M. Collins, Olympia J. Snowe 

U.S. House of Representatives: Tom Allen 

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

VA Office of Inspector General 22