Department of Veterans Affairs 

Office of Inspector General 

Combined Assessment Program 

Review of the 

Washington, DC, 

VA Medical Center 

Report No. 06-00627-232 September 29, 2006

VA Office of Inspector General 

Washington, DC 20420 
Office of Inspector General 

Combined Assessment Program Reviews 

Combined Assessment Program (CAP) reviews are part of the Office of Inspector 

General's (OIG's) efforts to ensure that high quality health care services are 

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. 

• Determine if management controls ensure compliance with regulations and VA

policies, assist management in achieving program goals, and minimize 

vulnerability to fraud, waste, and abuse. 

• 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 Washington, DC, VA Medical Center 

Contents 

Page 

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

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

Medical Center Profile..................................................................................................... 1

Objectives and Scope of the CAP Review ...................................................................... 2

Results of Review.................................................................................................4

Opportunities for Improvement ....................................................................................... 4

Contract Nursing Home Program Review ................................................................... 4

Quality Management.................................................................................................... 5

Breast Cancer Management ......................................................................................... 5

Other Observations.......................................................................................................... 6

Diabetes and Atypical Antipsychotic Medications...................................................... 6 

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

All Employee Survey ................................................................................................... 8

Survey of Healthcare Experiences of Patients............................................................. 9

Appendixes 

A. VISN Director’s Comments..................................................................................... 12

B. Medical Center Director’s Comments ..................................................................... 15

C. OIG Contact and Staff Acknowledgments............................................................... 19

D. Report Distribution .................................................................................................. 20

VA Office of Inspector General 
Combined Assessment Program Review of the Washington, DC, VA Medical Center 

Executive Summary 

Introduction 

The Department of Veterans Affairs, Office of Inspector General (OIG), Office of 

Healthcare Inspections (OHI) conducted a program review of the Washington, DC,

Veterans Affairs Medical Center (VAMC or the medical center) during the week of 

May 22–26, 2006. The purpose of the review was to evaluate selected operations

focusing on patient care administration, quality management (QM), and administrative 

management controls. During the review, the Office of Investigations provided 4 fraud 

and integrity awareness briefings to 491 medical center employees. The medical center is 

part of Veterans Integrated Service Network (VISN) 5. 

Results of Review 

This review focused on seven areas. The medical center complied with selected

standards in the following areas: 

• All Employee Survey (AES) 

• Diabetes and Atypical Antipsychotic Medications 

• Environment of Care (EOC) 

• Survey of Healthcare Experiences of Patients (SHEP) 

We identified three areas that needed additional management attention. To improve

operations we made the following recommendations: 

• Improve internal administrative controls over the Contract Nursing Home (CNH) 

program.

• Strengthen the peer review program, mortality analysis, and adverse event disclosure. 

• Ensure documentation of patient notification of mammography results in the medical 

center’s Veterans Health Information Systems and Technology Architecture (VistA). 

This report was prepared under the direction of Mr. Randall Snow, JD, Associate 

Director, and Ms. Gail Bozzelli, RN, Health Systems Specialist, Washington, DC, Office 

of Healthcare Inspections. 

VA Office of Inspector General i 
Combined Assessment Program Review of the Washington, DC, VA Medical Center 

VISN and Medical Center Director Comments 

The VISN and Medical Center Directors agreed with the CAP review findings and 

recommendations and provided acceptable improvement plans. (See Appendices A and 

B, pages 12–20, 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 Washington, DC, VA Medical Center 

Introduction 

Medical Center Profile 

Organization. The medical center is a tertiary care hospital that provides a broad range 

of inpatient and outpatient health care services. Outpatient care is also provided at 

community based clinics located in Greenbelt and Charlotte Hall, MD; Alexandria, VA; 

and southeast Washington, DC. The medical center is part of Veterans Integrated Service 

Network (VISN) 5 and serves a population of about 48,395 enrolled veterans in a primary

service area that includes metropolitan Washington, DC, and selected counties in 

Maryland and Virginia.

Specialized Programs. The medical center’s programs include the following: 

• Cardio-Thoracic Surgery 

• Eastern Pacemaker Surveillance Center 

• Geriatric Rehabilitation 

• Home Based Primary Care 

• Hospice and Palliative Care 

• Information Management Field Office 

• Institute for Clinical Research 

• National Media Development Center 

• Office of Special Projects 

• War Related Illness and Injury Study Center

Affiliations and Research. The medical center is affiliated with Howard University 

School of Medicine, Georgetown University School of Medicine, and George 

Washington University Medical School. 

Resources. In fiscal year (FY) 2005, medical care expenditures totaled $238 million 

(exclusive of Medical Care Collection Fund collections, alternative revenues, and specific

purpose dollars). FY 2005 staffing was 721 full-time equivalent employees (FTE), 

including 152 physician, 555 nurse, and 14 nurse practitioner FTE. 

Workload. In FY 2005, the medical center treated 48,395 unique patients. The inpatient

care workload totaled 28,658 admissions, and the average daily census was 188, 

including long term care patients. The outpatient care workload was 419,269 visits. 

VA Office of Inspector General 1 
Combined Assessment Program Review of the Washington, DC, VA Medical Center 

Objectives and Scope of the CAP Review 

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, quality management, and administrative controls. 

• 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, QM, and management controls. 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. Management controls are the policies, procedures, and 

information systems used to safeguard assets, prevent errors and fraud, and ensure that 

organizational goals are met. 

In performing the review, we inspected work areas; interviewed managers and 

employees; and reviewed clinical and administrative records. The review covered the 

following seven activities: 

All Employee Survey 

Breast Cancer Management 

Contract Nursing Home Program 

Diabetes and Patients on Atypical 

Antipsychotic Medications 

Environment of Care 

Quality Management 

Survey of Healthcare Experiences of 

Patients 

During this review, we also presented 4 fraud and integrity awareness briefings for 491 

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. 

The review covered facility operations for FY 2005 through May 8, 2006, and was done

in accordance with OIG standard operating procedures for CAP reviews. We also

followed up on selected recommendations from our prior CAP review of the medical

center (Combined Assessment Program Review of the Washington, DC VA Medical 

Center, Report No. 02-02172-129, July 14, 2003). In this report we summarize selected

Focused Inspections and state opportunities for improvement. Recommendations pertain 

to issues that are significant enough to be monitored by the OIG until corrective actions

are implemented. Activities in the section titled “Other Observations” have no reportable 

conditions. 

VA Office of Inspector General 2 
Combined Assessment Program Review of the Washington, DC, VA Medical Center 

Results of Review 

Opportunities for Improvement 

Contract Nursing Home Program 

Conditions Needing Improvement. CNH Program Managers needed to improve

monitoring and oversight of CNH activities and amend local policies to ensure that 

veterans receive quality care in safe environments. 

Review Team. Veterans Health Administration (VHA) Handbook 1143.2, VHA 

Community Nursing Home Oversight Procedures, requires that a CNH Review Team be 

established for evaluation of nursing homes that care for veterans. The CNH Review

Team must include a registered nurse, a social worker, and other disciplines as 

appropriate to evaluate areas of non-compliance. A designated social worker was not 

available to perform monthly visits to CNHs. The CNH social worker became the CNH

Review Team Coordinator and for several months there were no CNH visits by a social 

worker. Temporary coverage was arranged, but that staff consistently failed to make 

required visits and /or phone contact with patients in CNHs. Also, initial and annual 

reviews of CNH for contract award were not properly documented (findings, 

recommendations, ongoing monitoring, and follow-up services). 

Oversight Committee. A CNH Oversight Committee with upper-management level 

representation was established in May 2006. VHA policy requires oversight of the CNH

Review Team to ensure that veterans receive quality care. Facilities with CNH programs 

must establish a CNH multidisciplinary oversight committee with upper management 

representation from social work, nursing, quality management, acquisition, and medical 

staff to effectively administer and monitor the program. The committee is established by 

the Medical Center Director and is responsible for completing and monitoring mandated 

CNH reviews. 

Policy. The local policy did not reflect the establishment of the Oversight Committee. 

Recommended Improvement Action 1: We recommend that the VISN Director ensure 

that the Medical Center Director requires: (a) social worker and nursing visits are 

conducted per VHA Handbook 1143.2, (b) continuation of a CNH Oversight Committee 

activity with multidisciplinary upper-management level representation, (c) amendment of 

local policy to meet VHA requirements for a CNH Oversight Committee, and (d) use of 

VA Nursing Home evaluation tools to report adverse events and improve communication 

between nursing homes and CNH program managers. 

VA Office of Inspector General 3 
Combined Assessment Program Review of the Washington, DC, VA Medical Center 

Quality Management 

Conditions Needing Improvement. The QM program was generally effective, with 

appropriate review structures in place for 11 of the 14 program activities reviewed. 

However the peer review process, disclosure of adverse events to patients, and the 

mortality analysis needed improvement. 

Peer Review Process. Peer review is the ongoing evaluation of a provider’s professional 

performance by their colleagues. The Veterans Health Administration (VHA) peer

review directive required medical centers to develop a peer review policy by March 4,

2005. The medical center established a peer review program in November 2005.

However, the program was not fully implemented at the time of our visit. Prior to that 

time, there was no coordinated effort to review practice patterns, collect and trend data, 

and identify areas to improve patient care. The VHA policy also requires completion of 

all peer reviews within 45 days of discovery of an event. In a random sample of 38 

reviews, 7 were not completed within this time frame. 

Adverse Event Disclosure. When serious adverse events occur as a result of patient care, 

VHA policy requires staff to discuss the events with patients, inform them of their right

to file tort or benefit claims, and document the notification in the patient’s medical 

record. In a sample of 21 patients who experienced adverse events from January 2005 

through May 2006 we found 20 patient medical records with documentation of patient 

notification; of these 20, only 3 documented advisement of the right to file tort or benefit 

claims. 

Mortality Trending. Although the facility trended deaths in considerable detail including 

the time and location of the death, it did not trend deaths by individual provider as 

required by VHA policy. 

Recommended Improvement Action 2: We recommend that the VISN Director ensure 

that the Medical Center Director requires that: (a) the formal peer review program is 

strengthened, (b) providers complete peer reviews within the 45-day requirement, (c) 

clinicians fully inform patients who experience adverse events of tort and benefit 

remedies, and (d) QM Staff trend deaths by individual provider. 

Breast Cancer Management 

Condition Needing Improvement. VHA breast cancer screening performance measures 

assess the percent of patients screened according to prescribed timeframes. Timely

screening, diagnosis, communication, interdisciplinary treatment planning, and treatment 

are essential to early detection, appropriate management, and optimal patient outcomes. 

We assessed these items in a sample of 10 patients who were newly diagnosed with 

breast cancer. To determine compliance, we used standards outlined in VHA and local 

VA Office of Inspector General 4 
Combined Assessment Program Review of the Washington, DC, VA Medical Center 

policies. The medical center needed to ensure that patient notification of normal and 

abnormal mammography results were documented in VistA. 

Screening and Referral. The system exceeded the VHA performance measure for breast 

cancer screening in 2 of the 4 quarters for FY 2005, and exceeded the national standard in 

all 4 quarters, as indicated in the graph below. Nine of the 10 cases we reviewed

received appropriate screening, with 1 case not receiving appropriate screening due to 

patient issues such as no shows for scheduled appointments. 

All 10 patients received mammography results within 30 days, timely biopsy procedures, 

and timely consultations for general surgery; while 9 of the patients received timely 

hematology/oncology, and radiation therapy consults. Nine of the patients requiring 

multiple treatment modalities had documentation of interdisciplinary treatment plans in 

the medical record. The tenth patient did not require any further treatment after the 

completion of the biopsy. 

Breast Cancer Screening

WASHINGTON DC VAMC

97

88

85

83

85 86

100

88

94 95 94

84

30

35

40

45

50

55

60

65

70

75

80

85

90

95

100

Qtr 1 Qtr 2 Qtr 3 Qtr 4

Percent

Facility

VISN

National

Better

WASHINGTON DC VAMC FY 2005

Performance Measure Scores

Fully

Satisfactory

Score = 85%

Patients 

appropriately

screened

Mammography 

results reported

to patient within 

30 days

Patients 

appropriately

notified of their 

diagnoses 

Patients 

received timely

consultations 

Patients 

received timely

biopsy

procedure 

Documentation of 

interdisciplinary 

treatment plan 

9/10 10/10 10/10 10/10 9/10 9/10

VA Office of Inspector General 5 
Combined Assessment Program Review of the Washington, DC, VA Medical Center 

Documentation of Results Notification. Documentation of patient notification of normal 

and abnormal results was not recorded in the medical center’s VistA. The medical center 

refers patients to an outside facility to perform mammography. VHA regulation requires 

entry of all mammography reports, regardless of where they are performed, into VistA. 

The off-site mammography facility is expected to also provide a written summary of the 

report to the patient. To ensure continuity of care and compliance with prescribed 

documentation practices, the notification must be documented in the patient’s off-site 

medical record, as well as in the referring medical center’s VistA. 

Recommended Improvement Action 3: We recommend that the VISN Director ensure 

that the Medical Center Director requires documentation of patient notification of

mammography results in VistA. 

Other Observations 

Diabetes and Atypical Antipsychotic Medications 

Mental health patients receiving atypical antipsychotic medications (medications that 

cause fewer neurological side effects but increase the patient’s risk for the development

of diabetes) require effective diabetes screening, monitoring, and treatment. 

VHA clinical practice guidelines suggest that diabetic patients’ blood glucose levels be at 

a therapeutically acceptable level (Hemoglobin A1c (HbA1c) below 9 percent) to avoid 

symptoms of hyperglycemia; blood pressure should be less than or equal to 140/90 

millimeters of mercury (mmHg); and low density lipoprotein cholesterol (LDL-C) should 

be less than 120 milligrams per deciliter (mg/dl). The system must meet these standards

to receive fully satisfactory ratings for these performance measures. 

The medical center met or exceeded VHA performance measures for LDL-C of less than 

120 mg/dl for the last 5 reporting quarters. Blood pressure management scores 

consistently improved in FY 2005 and were fully satisfactory for 2 quarters of FY 2006, 

as demonstrated in the following charts. 

VA Office of Inspector General 6 
Combined Assessment Program Review of the Washington, DC, VA Medical Center 

Diabetes Detection and Management

LDL-C < 120

Washington, DC

70 72

81

76 77 79

71

78

88 87

73

75

25

30

35

40

45

50

55

60

65

70

75

80

85

90

95

100

Qtr 1 Qtr 2 Qtr 3 Qtr 4

Percent

Facility

VISN

National

Better FY 2005 Performance Measure Scores

Fully

Satisfactory

Score = 75

Diabetes Detection and Management

B/P < 140/90

Washington, DC

67

64

81

74 75

78

82

58

66

54

63

73

15

20

25

30

35

40

45

50

55

60

65

70

75

80

85

90

95

100

Qtr 1 Qtr 2 Qtr 3 Qtr 4

Percent

Facility

VISN

National

Better FY 2005 Performance Measure Scores

Fully

Satisfactory

Score = 72

The medical center had less than satisfactory scores for FY 2005 for HbA1c, but has 

taken the following action to improve: 

• Measuring HbA1c at the point of care. 

• Initiation of a health improvement program for the seriously mentally ill. 

• Diabetes monitoring education for patients. 

• Addition of a full-time pharmacist in the Diabetes clinic. 

• Telehealth program for patients to monitor their blood sugars at home and transmit 

the data to their medical record electronically. 

VA Office of Inspector General 7 
Combined Assessment Program Review of the Washington, DC, VA Medical Center 

Diabetes Detection and Management

HbA1c >9

Washington, DC

16

25

15

13

16

15

14

24

21

16

21

15

0

5

10

15

20

25

30

Qtr 1 Qtr 2 Qtr 3 Qtr 4

Percent

Facility

VISN

National

Better FY 2005 Performance Measure Scores

Fully

Satisfactory

Score = 15

We reviewed a sample of 13 patients who were on one or more atypical antipsychotic 

medications for at least 90 days. Two of the 13 had diabetes, which developed after the 

initiation of atypical antipsychotic medications in both patients. See table for a summary

of results. 

Diabetic 

patients with 

HbA1c more 

than 9 percent 

Diabetic 

patients with 

B/P less than 

140/90 

mm/Hg

Diabetic 

patients with 

LDL-C less 

than 120mg/dl 

Non-diabetic 

patients 

appropriately 

screened 

1/2 2/2 2/2 11/11

Environment of Care 

The purpose of the evaluation is to determine if the medical center maintains a safe and 

clean healthcare environment. The medical center must establish a comprehensive EOC 

program that fully meets all VHA, Occupational Safety and Health Administration, and 

Joint Commission on Accreditation of Healthcare Organizations standards. To evaluate

EOC, clinical and non-clinical areas are inspected for cleanliness, safety, infection 

control, and general maintenance. The medical center maintained a clean and safe 

environment with no reportable findings. 

All Employee Survey

The Executive Career Field (ECF) Performance Plan for FY 2005 directs VISNs to 

widely disseminate results from the 2004 AES by, at a minimum, conducting a town hall 

meeting open to all employees at each facility during the rating period. VISNs were

VA Office of Inspector General 8 
Combined Assessment Program Review of the Washington, DC, VA Medical Center 

directed to analyze the survey results and formulate plans to address action items for 

improvements by September 30, 2004. Such plans must demonstrate milestones that

include time lines and measures that assess achievement. 

The medical center met all requirements of Performance Measure 22 in the ECF 

performance plan for FY 2005. Facility analysis of the survey results targeted Conflict 

Resolution, Job Control, and Work and Family Balance as opportunities for 

improvement. An action plan, which had measurable objectives with identified timelines 

and milestones, was developed by the September 2004 deadline. Actions taken to 

improve the work environment are well documented, with an emphasis on 

communications and customer service. The medical center established a Veterans 

Service Advocacy Council, which directly deals with employee satisfaction issues. 

Mandatory customer service training was started in November 2005 for all employees.

Survey results and the action plan were disseminated to the employees by e-mail, staff 

meetings, town hall meetings, newsletters called “Sandygrams” from the Director, and 

the “Irving Street Journal,” an internal medical center publication. 

Administration of the 2006 All Employee Survey was completed just prior to the CAP 

review, and the employee participation rate dramatically increased to 89 percent from 33

percent in 2004. 

Survey of Healthcare Experiences of Patients 

Veteran patient satisfaction surveying is designed to promote health care quality 

assessment and improvement strategies that address patients' needs and concerns, as 

defined by patients. In 1995, VHA began surveying its patients using a standardized 

instrument modeled from the Picker Institute, a non-profit health care surveying group. 

The Performance Analysis Center for Excellence of the Office of Quality & Performance 

is the analytical, methodological, and reporting staff for SHEP. To meet Measure 21 of 

the VHA Executive Career Field Performance Plan for FY 2006 the medical center must 

achieve patient satisfaction scores of very good or excellent in 77 percent of outpatients 

and 76 percent of inpatients surveyed. The following graphs show the medical center’s 

SHEP results for inpatients and outpatients. 

VA Office of Inspector General 9 
Combined Assessment Program Review of the Washington, DC, VA Medical Center 

Facility Name Access

Coordination of

CareCourtesyEducation &Information

Emotional SupportFa

mily

InvolvementPhysical Co

mfort

Preferences

Transition

National 80.73 78.27 89.40 67.36 65.08 75.37 83.35 73.98 69.52

VISN 75.8- 74.5- 85.1- 63.2- 60.1- 74.40 79.6- 69- 66.9-

Medical Center 78.80 76.50 84.2- 66.20 60.9- 74.00 80.1- 67.3- 64.1-

INPATIENT SHEP RESULTS

Washington, DC

* Less than 30

"+" "-" Indicate Results that are Significantly Better

"+" or

Worse "-" than the National

Dates of Survey Reporting period:

Q3, Q4 FY 2005

Access

Continuity of Care

Courtesy

Education &

Information

Emotional

Support

Overall

Coordination

Pharmacy Mailed

Pharmacy Pick-up

Preferences

Specialist Care

Visit Coordination

National 81.5 78 95.3 73.1 83.7 76.2 82.6 66.5 82.2 80.7 85.2

VISN 81.2 76.4 95.1 71.5 82.6 76.6 76.5 63.7 81.3 77.9 85.1

Outpatient Clinics - Overall 81.7 83.2 93.5 72.1 85.7 75.7 77.1 61.5 82 80.2 82.9

_ WASHINGTON OUTPATIENT CLINIC 80.8 84.5 93.2 70.5 85 74.7 * * 81.2 79.8 82

_ ALEXANDRIA OUTPATIENT CLINIC 85.3 67.5 93.7 80.4 89.7 76.2 74.3 * 83.4 * 83.5

_ SOUTHEAST WASHINGTON CBOC 85.6 + 80.9 + 96.8 + 77.9 + 84.9 + 83.2 + * * 84.4 + * 89.5 +

_ PRINCE GEORGES COUNTY 85.5 71.4 95.8 78.9 89.6 81.5 69.1 * 84.4 * 86.3

_ CHARLOTTE HALL OUTPATIENT CLINIC 93.3 + 72.1 97 91.5 + 94.7 + 90.3 + 74.7 * 93.1 + * 94.6 +

OUTPATIENT SHEP RESULTS

Washington, DC Dates of survey reporting period:

Q1 FY 2006

* Less than 30 Respondents

"+" "-" Indicate Results that are Significantly Better "+" or

Worse "-" than the National Average

VA Office of Inspector General 10 
Combined Assessment Program Review of the Washington, DC, VA Medical Center 

The medical center has an organized, systematic approach to analysis and improvement

of SHEP data scores. Data is analyzed daily, and trend lines and appropriate statistics are 

applied monthly. Actions taken to improve scores include the addition of nursing staff, 

scripting exercises, and changes in departmental structure to improve pharmacy access. 

The medical center was awarded the Customer Service Award from the Veterans Affairs 

Undersecretary for Health for outstanding work in improving emotional support to 

inpatients. To improve emotional support for patients, the medical center analyzed SHEP 

and patient compliments/complaints data; the analysis showed a direct correlation to 

overall satisfaction scores reported by veterans. 

VA Office of Inspector General 11 
Combined Assessment Program Review of the Washington, DC, VA Medical Center

Appendix A 

VISN Director Comments

Department of 

Veterans Affairs Memorandum

Date: August 15, 2006 

From: Network Director (10N5) 

Subject: Combined Assessment Program Review Washington

DC VAMC 

To: Combined Assessment Program Review, Washington DC 

VAMC 

1. Attached please find the action plan for the 

recommendations from the Office of the Inspector General 

Combined Assessment Program Review conducted May 

22, 2006 - May 26, 2006. 

2. We appreciate the professionalism demonstrated by 

your team during this review process. 

3. If you have any questions regarding this report, please 

contact Mr. Sanford Garfunkel, Director of the 

Washington DC VAMC at 202-745-8100. 

 (original signed by:)

JAMES J. NOCKS, M.D., M.S.H.A. 

VA Office of Inspector General 12 
Combined Assessment Program Review of the Washington, DC, VA Medical Center

VISN Director’s Comments 

to Office of Inspector General’s Report 

The following VISN Director’s comments are submitted in 

response to the recommendations in the Office of Inspector

General Report: 

OIG Recommendations

Recommended Improvement Action 1. We recommend

that the VISN Director ensure that the Medical Center 

Director requires that: (a) social worker and nursing visits are 

conducted per VHA Handbook 1143.2, (b) the continuation 

of a CNH Oversight Committee with multidisciplinary uppermanagement level representation, (c) local policy is amended 

to meet VHA requirements for a CNH Oversight Committee,

and (d) the use of VA Nursing Home evaluation tools to

report adverse events and improve communication between 

nursing homes and CNH program managers. 

Concur Target Completion Date: 9/06 

Recommended Improvement Action 2. We recommend

that the VISN Director ensure that the Medical Center 

Director requires that: (a) the formal peer review program is 

strengthened, (b) providers complete peer review within the 

45-day requirement, (c) responsible clinicians fully inform 

patients, who experience adverse events, of tort and benefit 

remedies, and (d) QM Staff trend deaths by individual 

provider. 

Concur Target Completion Date: 9/06 

Recommended Improvement Action 3. We recommend

that the VISN Director ensure that the Medical Center 

Director requires documentation of patient notification of

mammography results VistA. 

Concur Target Completion Date: 9/06 

VA Office of Inspector General 13 
Combined Assessment Program Review of the Washington, DC, VA Medical Center

Appendix B 

Medical Center Director Comments 

Department of 

Veterans Affairs Memorandum

Date: August 14, 2006 

From: Medical Center Director, Washington, DC VA Medical 

Center 

Subject: Combined Assessment Program Review of the 

Washington, DC VA Medical Center

To: VISN Director, Capitol Health Network, VISN 5 (10N5) 

A Combined Assessment Program Review by the Office 

of the Inspector General was conducted at the Washington 

VA Medical Center from May 22, 2006 - May 26, 2006. 

Attached, please find the draft report of the findings and 

corrective actions. Implementation of the corrective 

actions is well underway. 

If you have any questions or need additional information, 

please contact Ms. Deborah Amdur at (202) 745-8212. 

 (original signed by:)

SANFORD M. GARFUNKEL 

Medical Center Director 

 

VA Office of Inspector General 14 
Combined Assessment Program Review of the Washington, DC, VA Medical Center

Medical Center Director’s Comments 

to Office of Inspector General’s Report 

The following Medical Center Director’s comments are 

submitted in response to the recommendations in the Office 

of Inspector General Report: 

OIG Recommendations

Recommended Improvement Action 1. We recommend

that the VISN Director ensure that the Medical Center 

Director requires (a) Social worker and nursing visits are 

conducted per VHA Handbook 1143.2, (b) continuation of a 

CNH Oversight Committee with multidisciplinary uppermanagement level representation, (c) amend local policy to 

meet VHA requirements for a CNH Oversight Committee, 

and (d) use VA Nursing Home evaluation tools to report 

adverse events and improve communication between nursing 

homes and CNH program managers. 

Concur: Yes Target Completion Date: 9/06 

Social Work and Nursing Visits: 

In compliance with the VHA Handbook 1143.2, all veterans 

in Community Nursing Homes under VA Contract are being 

visited on a monthly basis with nursing and social work

visiting on alternating months. Permanent staff is being 

hired to fulfill these roles; in the interim, existing staff have 

taken on this additional responsibility. 

CNH Oversight Committee: 

The CNH Oversight Committee continues to meet quarterly 

to discuss community nursing home-related issues. 

Committee representation consists of representatives from 

social work, nursing, quality management, contracting, and 

medical staff. 

Amendment of Local CNH Policy: 

VA Office of Inspector General 15 
Combined Assessment Program Review of the Washington, DC, VA Medical Center

Washington VA Medical Center Community Services Policy 

Memorandum No. 4 May, 2006, establishes requirements for

a CNH Oversight Committee. 

 Use of VA Nursing Home Evaluation Tools 

VA Community Nursing Home Website has been 

incorporated as the evaluation tool to report adverse events 

and to improve communication between nursing homes and 

CNH program managers. The Community Nursing Home

Exclusion Review form is being used to document the annual 

review process for community nursing homes. The monthly 

visit form is in a template format and is being utilized to 

provide information that must be evaluated and documented 

on each community nursing home monthly visit. The 

Adverse and/or Sentinel Event Reporting form is used to 

report adverse and/or sentinel events involving contract 

patients in Community Nursing Homes. The Centers for 

Medicaid and Medicare (CMS) Website that lists 

deficiencies, staffing and performance on quality measures 

for all certified nursing homes is being used by the CNH 

Review Team. The Annual Certification Report via the CNH 

Website has been initiated. 

Recommended Improvement Action 2. We recommend

that the VISN Director ensure that the Medical Center 

Director requires (a) strengthening the formal peer review

program, (b) providers complete peer review within the 45-

day requirement, (c) responsible clinicians fully inform

patient’s who experience adverse events of tort and benefit 

remedies, and (d) QM Staff trend deaths by individual 

provider. 

Concur: Yes Target Completion Date: 9/06 

Peer Review Program: A formal process for peer review is 

now in place. The Peer Review Committee has met monthly 

since 5/06. When a case is identified, the records are 

reviewed by another provider with expertise in the field of the 

provider(s) in question. Once the records have been reviewed 

by the provider; the Peer Review Committee then reviews the 

record as well as the recommendations from the individual 

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Combined Assessment Program Review of the Washington, DC, VA Medical Center

peer review. The Committee decides, based on the review, 

what action, if any should be taken. 

Completion of Peer Reviews: Since 5/06, 9 cases have been 

peer reviewed. Only one of these cases was not completed in 

the 45 day time period. During the CAP Review, 38 records

were reviewed and 7 were not completed within the 45 day 

time period. The organization has gone from an 18%

delinquent rate to a 10% delinquent rate. This reflects the 

improvement that has occurred since 5/06. This Medical 

Center will continue to monitor the timeliness of reviews and 

expects to be at 100% by 9/06. 

Disclosure: A full disclosure process is in place including a 

templated note that includes all required elements of

disclosure. All providers have been educated about the 

disclosure requirements and the use of the disclosure 

template. Since 5/06, there has been 1 case of a patient with a 

serious adverse event. Full disclosure occurred including 

informing the patient of their right to file a benefit or tort 

claim. The disclosure was documented in the medical record. 

The Quality Management Department will continue to 

monitor all cases for appropriate disclosure and 

documentation. 

Trending of Deaths by Individual Provider: the review of

deaths by individual provider was initiated 7/06. QM will 

begin reporting death trends by individual provider at the 

Medical Executive Committee in 9/06. This will be done on 

a quarterly basis. 

Recommended Improvement Action 3. We recommend

that the VISN Director ensure that the Medical Center 

Director requires documentation of patient notification of

mammography results VistA. 

Concur: Yes Target Completion Date: 9/06 

Documentation of Patient Notification of Mammography 

Results: 

The following plan is being implemented by the Women's

Health Clinic: 

VA Office of Inspector General 17 
Combined Assessment Program Review of the Washington, DC, VA Medical Center

The Breast Clinic Surgeon will review all mammogram 

reports. 

For negative reports: 

The patient will be informed of their results and the 

recommended time frame for their next visit telephonically or

by mail. Method of notification will be documented in CPRS 

using an established template. 

For all positive reports: 

The patient will be notified either telephonically or by mail 

that there is an abnormal finding on their mammogram report. 

They will be immediately scheduled for an appointment in the 

Breast Clinic. The Breast Clinic Surgeon will discuss the 

results and plan of care with the patient and document this 

discussion and plan of care in CPRS. 

VA Office of Inspector General 18 
Combined Assessment Program Review of the Washington, DC, VA Medical Center

Appendix C 

OIG Contact and Staff Acknowledgments 

OIG Contact Randall Snow, J.D. Associate Director 

Regional Office of Healthcare Inspections 

Washington, DC 

202-565-8451 

Acknowledgments 

Tom Bennett 

Gail Bozzelli 

Donna Giroux 

Nelson Miranda 

Carol Torczon 

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Combined Assessment Program Review of the Washington, DC, VA Medical Center

Appendix D 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, Veterans Integrated Service Network 5 (10N5)

Director, VA Medical Center, Washington, DC 

Non-VA Distribution

House Committee on Veterans’ Affairs 

House Appropriations Subcommittee on Military Quality of Life and Veterans Affairs 

House Committee on Government Reform

Senate Committee on Veterans’ Affairs 

Senate Appropriations Subcommittee on Military Construction and Veterans Affairs 

Senate Committee on Homeland Security and Governmental Affairs 

National Veterans Service Organizations 

Government Accountability Office 

Office of Management and Budget 

U.S. House of Representatives: Eleanor Holmes Norton 

This report will be available in the near future on the OIG’s Web site at 

http://www.va.gov/oig/52/reports/mainlist.htm. This report will remain on the OIG Web 

site for at least 2 fiscal years after it is issued. 

VA Office of Inspector General 20