Department of Veterans Affairs 

Office of Inspector General 

Combined Assessment Program 

Review of the 

Atlanta VA Medical Center 

Atlanta, Georgia 

Report No. 06-01571-231 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 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. 

• 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 Atlanta VA Medical Center, Atlanta, Georgia 

Contents 

Page 

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

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

Facility Profile ................................................................................................................. 1

Objectives and Scope of the CAP Review ...................................................................... 1

Follow-Up on Prior CAP Review Recommendations..................................................... 2

Results of Review........................................................................................................... 3

Breast Cancer Management...................................................................................... 3

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

Contract Community Nursing Home ....................................................................... 4

Appendixes 

A. VISN Director Comments .......................................................................................... 6

B. Medical Center Director Comments........................................................................... 8

C. OIG Contact and Staff Acknowledgments................................................................ 11

D. Report Distribution ................................................................................................... 12

VA Office of Inspector General 
Combined Assessment Program Review of the Atlanta VA Medical Center, Atlanta, Georgia 

Executive Summary 

Introduction 

During the week of May 1–5, 2006, the Office of Inspector General (OIG) conducted a 

Combined Assessment Program (CAP) review of the Atlanta VA Medical Center 

(referred to as the medical center). 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 295

employees. The Medical Center is under the jurisdiction of Veterans Integrated Service 

Network (VISN) 7. 

Results of Review 

The CAP review covered six operational activities. As identified below, the medical 

center complied with selected standards in five areas. The remaining area resulted in

recommendations for improvement. 

The system complied with selected standards in the following areas: 

• All Employee Survey 

• Breast Cancer 

• Diabetes and Atypical Antipsychotic Medication 

• Environment of Care 

• Quality Management 

To improve operations, we recommended that the medical center improve program

oversight of Contract Community Nursing Homes. 

This report was prepared under the direction of Ms. Linda G. DeLong, Director, CAP

Review Coordinator, Dallas Regional Office of Healthcare Inspections. 

VA Office of Inspector General i 
Combined Assessment Program Review of the Atlanta VA Medical Center, Atlanta, Georgia 

VISN and Medical Center Director Comments 

The VISN 16 and Medical Center Directors agreed with the findings and 

recommendations and provided acceptable implementation plans. (See Appendixes A

and B, pages 6–9 for the full text of the Directors’ comments.) We will follow up on 

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 Atlanta VA Medical Center, Atlanta, Georgia 

Introduction 

Facility Profile 

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

range of inpatient and outpatient health care services. There are four community based 

outpatient clinics located in Lawrenceville, Oakwood, Smyrna, and Eastpoint, Georgia. 

The medical center is part of VISN 7 and serves a veteran population of about 387,000 in 

a primary service area that includes portions of Alabama, South Carolina, and 45 counties 

in Georgia.

Programs. The medical center provides primary and specialized outpatient health care, 

extended care, acute and intermediate medical, surgical, and psychiatric care services 

with most major specialties and subspecialties. Currently the facility has 121 operating 

hospital beds and 100 nursing home beds. The medical center functions as the Primary 

Receiving Center in the VA/Department of Defense Contingency Planning Process and 

as a Federal Coordinating Hospital in the National Disaster Medical System. 

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

School of Medicine, and supports 125 medical resident positions in 33 training programs. 

In total, there are 35 schools with active affiliation agreements with the medical center. 

In fiscal year (FY) 2005, the medical center research program had over 660 projects and a 

budget of approximately $29 million. Important areas of research include infectious 

disease, bone research, and a Center of Excellence in Rehabilitation Research and 

Development dealing with veterans with visual impairment.

Resources. In FY 2005, medical care expenditures totaled $240.6 million. The FY 2006 

medical care budget is $267.6 million. FY 2005 staffing totaled 1,755 full-time 

equivalent (FTE) employees, including 163 physician and 418 nursing FTE. 

Workload. In FY 2005, the medical center treated 57,350 unique outpatients. The 

medical center provided 36,750 inpatient days, 3,266 inpatient days in the Psychosocial 

Residential Rehabilitation Treatment Program (PRRTP), and 28,003 inpatient days in the 

Nursing Home Care Unit. The inpatient care workload totaled 5,528 discharges with a 

average daily census of 100 hospital, 76 Nursing Home Care Unit, and 8 PRRTP

Veterans. The outpatient workload included 606,064 visits. 

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. The objectives of the CAP review are to: 

• Conduct recurring evaluations of selected health care facility operations focusing on

patient care and quality management. 

VA Office of Inspector General 1 
Combined Assessment Program Review of the Atlanta VA Medical Center, Atlanta, Georgia 

• 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 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, employees,

and patients; and reviewed clinical records. The review covered the following 6 

activities: 

All Employee Surveys 

Breast Cancer Management 

Community Nursing Home Contracts 

Diabetes and Atypical Antipsychotic Medication 

Environment of Care 

Quality Management 

As a part of the review, we interviewed 30 patients to survey satisfaction with timeliness 

of service and the quality of care. The survey results were shared with medical center 

managers. 

Activities needing improvement are discussed in the Opportunities for Improvement 

section (page 4). Recommendations pertain to issues that are significant enough to be 

monitored by the OIG until corrective actions are implemented. 

During this review, we also presented fraud and integrity awareness briefings for 295 

employees. These briefings covered procedures for reporting suspected criminal activity 

to the OIG and included case-specific examples illustrating procurement fraud, false 

claims, conflicts of interest, and bribery. 

Follow-Up on Prior CAP Review Recommendations 

As part of this review, we followed up on recommendations from the prior CAP review

of the medical center (Combined Assessment Program Review of the VA Medical Center 

Atlanta, Georgia, Report No. 2002-02757-HI-0333, February 25, 2003). In 2002, it was 

identified that the Medical Center Director needed to improve cleanliness and safety 

deficiencies in the medical center and require that peer reviews be conducted and 

documented in accordance with local policy. 

Our May 2006 CAP review found that medical center management had implemented 

adequate corrective actions for the conditions identified. 

VA Office of Inspector General 2 
Combined Assessment Program Review of the Atlanta VA Medical Center, Atlanta, Georgia 

Results of Review 

Breast Cancer Management – Processes Were Timely and 

Appropriate 

The VHA breast cancer screening performance measure assesses the percent of patients 

screened according to prescribed timeframes. The medical center exceeded the target 

level for the last 2 quarters in FY 2005. Timely diagnosis, notification, interdisciplinary 

treatment planning, and treatment are essential to early detection, appropriate 

management, and optimal patient outcomes. 

Mammogram services were offered to the patients by fee-basis providers. Timely 

radiology, consultative, and treatment services were provided to the patients by the 

medical center. When indicated, an interdisciplinary treatment plan was developed, and 

providers promptly informed the patient of diagnosis and treatment options.

Breast Cancer Screening

Atlanta VAMC

84

86 87

81

83 84

75

88

82

88

84 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

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 

10/10 10/10 10/10 2/2 9/9

VA Office of Inspector General 3 
Combined Assessment Program Review of the Atlanta VA Medical Center, Atlanta, Georgia 

Opportunities for Improvement 

Contract Community Nursing Home – Program Oversight Needs To 

Be Improved 

Condition Needing Improvement. The medical center needed to establish a Contract 

Community Nursing Home (CNH) Oversight Committee for supervision at an upper

management-level. Medical centers are required to incorporate two separate entities, a 

CNH Review Team and a CNH Oversight Committee, with each being responsible for 

specific tasks. The CNH Review Team is responsible for the evaluations and inspections 

of the nursing homes as well as ongoing monitoring and follow-up visits with veterans 

who reside in the nursing homes. The CNH Oversight Committee consists of 

multidisciplinary management-level representatives who supervise the structure and 

methodology of the CNH Review Team and assure a plan for quality monitoring is 

implemented. The medical center had established a CNH Review Team, but had not 

organized a CNH Oversight Committee, which should include a medical staff 

representative as outlined by the VHA Handbook. The Medical Center Director has since 

created a CNH Oversight Committee to comply with VHA Handbook 1143.2, VHA 

Community Nursing Home Oversight Procedures. 

The medical center demonstrated a lack of oversight with ongoing monitoring and

follow-up visits in the nursing homes. Veterans, family members, and staff at the CNHs 

stated a social worker or nurse from the medical center did not visit on a regular basis, as 

required in the VHA Handbook. However, documentation in the electronic medical

record indicated monthly visits with the veteran and nursing home staff were conducted 

on a routine schedule. This concern was discussed with the Medical Center Director, and 

a Board of Investigation was immediately initiated.

There was no documented evidence that the facility met with the local Ombudsman 

offices. The purpose for interaction with the regional offices is to discuss issues of 

mutual interest and concern. The CNH coordinator communicated with the Ombudsman 

offices on an as needed basis without documenting the discussion. Following the onsite 

visit, the CNH Coordinator initiated annual meetings with the local Ombudsman offices; 

confirmation of these meetings will be indicated on the Certification Report. 

During the CNH review, healthcare inspectors discovered that a social worker failed to

follow up on possible neglect of a veteran upon discharge from the medical center in 

2001 as reported by a family member. From 2001–2005, the veteran continued in the 

same environment and was seen rarely at the medical center. In 2005, a hospital in the 

private sector admitted the veteran to a nursing home and notified the medical center. At 

that time, an elder abuse assessment was completed, which determined there were serious

concerns for the veteran’s safety and well-being. There was no documented evidence to 

VA Office of Inspector General 4 
Combined Assessment Program Review of the Atlanta VA Medical Center, Atlanta, Georgia 

support that medical center staff followed up regarding these concerns. This case was 

forwarded to the Medical Center Director for further action. 

Recommended Improvement Actions 1. We recommended that the VISN 

Director ensure that the Medical Center Director takes action to: (a) establish a Contract 

Community Nursing Home Oversight Committee, (b) implement recommendations given 

by the Board of Investigation, (c) develop and document collaboration between the CNH 

Coordinator and the local Ombudsman office, and (d) ensure clinicians report elder abuse 

as indicated in VHA Handbook 1143.2. 

VA Office of Inspector General 5 
Combined Assessment Program Review of the Atlanta VA Medical Center, Atlanta, Georgia

Appendix A 

VISN Director Comments

Department of 

Veterans Affairs Memorandum

Date: June 28, 2006 

From: VISN Director 

Subject: Response to Project # 2006-01571-HI-0315

To: Assistant Inspector General for Healthcare Inspections

Thru: Director, Management Review Services (10B5) 

The following VISN Director’s comments are submitted

in response to the recommendations in the Office of

Inspector General report. 

If you have any questions, please contact Wayne Saxton, 

Program Manager, VA Southeast Network, at phone

number 678-924-5700. 

VA Office of Inspector General 6 
Combined Assessment Program Review of the Atlanta VA Medical Center, Atlanta, Georgia

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 recommended 

that the VISN Director ensure that the Medical Center 

Director takes action to: (a) establish a Contract Community 

Nursing Home Oversight Committee; (b) implement 

recommendations given by the Board of Investigation; (c) 

develop and document collaboration between the CNH 

Coordinator and the local Ombudsman office; and (d) ensure 

clinicians report elder abuse as indicated in VHA Handbook 

1143.2. 

Concur 

I concur with the above recommendations. Per the attached 

memorandum from the Acting Medical Center Director, all 

recommendations have been implemented.

VA Office of Inspector General 7 
Combined Assessment Program Review of the Atlanta VA Medical Center, Atlanta, Georgia

Appendix B 

Medical Center Director Comments 

Department of 

Veterans Affairs Memorandum

Date: June 28, 2006 

From: Acting Director, Atlanta VAMC (508/00 

Subject: Response to Project # 2006-01571-HI-0315

To: Assistant Inspector General for Healthcare Inspections

Thru: Director, Management Review Services (10B5) 

The following Medical Center Director’s comments are 

submitted in response to the recommendations in the 

Office of Inspector General report. 

If you have any questions regarding this response, please 

contact Ted Johnson, MD, MPH, Manager for the

Geriatrics, Extended Care & Rehabilitation Service Line, 

at phone number 404-728-7775. 

VA Office of Inspector General 8 
Combined Assessment Program Review of the Atlanta VA Medical Center, Atlanta, Georgia

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 recommended 

that the VISN Director ensure that the Medical Center 

Director takes action to: (a) establish a Contract Community 

Nursing Home Oversight Committee; (b) implement 

recommendations given by the Board of Investigation; (c) 

develop and document collaboration between the CNH 

Coordinator and the local Ombudsman office; and (d) ensure 

clinicians report elder abuse as indicated in VHA Handbook 

1143.2. 

Concur 

Recommendation 1a: Establish a Contract Community 

Nursing Home Oversight Committee.

Concur. The Community Nursing Home (CNH) program

had included a Community Compliance Review Committee,

but its composition did not include a member of the medical 

staff (as is required in VHA Handbook 1143.2 dated June 4, 

2004). The Manager of the Geriatrics, Extended Care, & 

Rehabilitation Service Line was added as a member of this 

committee in May 2006, and the committee’s name was 

changed to the Community Nursing Home Oversight 

Committee. 

Recommendation 1b: Implement recommendations given 

by the Board of Investigation. 

Concur. All recommendations given by the Board of 

Investigation have been implemented. 

VA Office of Inspector General 9 
Combined Assessment Program Review of the Atlanta VA Medical Center, Atlanta, Georgia

Recommendation 1c: Develop and document collaboration 

between the CNH Coordinator and the local ombudsman 

office. 

Concur. The CNH Coordinator contacted all of the 

ombudsman offices in April to schedule quarterly meetings to

discuss veteran issues (evidence attached). At the request of 

the ombudsman, these meetings have been scheduled on a 

semi-annual basis and are supplemented by conference calls 

as needed, for individual issues. Documentation of these 

meetings will be reflected on the Certification Report. 

Recommendation 1d: Ensure clinicians report elder abuse 

as indicated in VHA Handbook 1143.2. 

Concur. All geriatric patients in Community Nursing 

Homes, Residential Care, our Nursing Home Care Unit and 

our Bronze Geriatrics clinic are screened by the Social 

Worker utilizing an elder abuse assessment template. 

Additionally, abuse screens are included in assessment 

templates with a link to our Medical Center Policy titled

“Identification and Reporting of Adult and Child Victims of 

Alleged or Suspected Abuse or Neglect or Assault”. Health 

Care Providers have been educated and reminded of the

policy by their team’s respective Social Worker. 

VA Office of Inspector General 10 
Combined Assessment Program Review of the Atlanta VA Medical Center Atlanta, Georgia

Appendix C 

OIG Contact and Staff Acknowledgments 

OIG Contact Linda G. DeLong, Director 

Dallas Regional Office of Healthcare Inspections 

(214) 253-3331 

Acknowledgments Karen Moore, Associate Director 

Shirley Carlile 

Roxanna Osegueda 

Wilma Reyes 

Marilyn Walls 

VA Office of Inspector General 11 
Combined Assessment Program Review of the Atlanta VA Medical Center Atlanta, Georgia

Appendix D 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, Veterans Integrated Service Network 7 

Director, Atlanta VA Medical Center 

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. Senate: 

 Saxby Chambliss 

 Johnny Isakson 

U.S Representatives: 

Cynthia McKinney 

David Scott 

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 12