Department of Veterans Affairs 

Office of Inspector General 

Office of Healthcare Inspections
 

Report No. 10-02996-84 

Combined Assessment Program Review
 

of the Northern Arizona
 

VA Health Care System
 

Prescott, Arizona
 

February 10, 2011 

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 crime awareness briefings 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 

Telephone: 1-800-488-8244 

E-Mail: vaoighotline@va.gov 

(Hotline Information: http://www.va.gov/oig/contacts/hotline.asp) 
CAP Review of the Northern Arizona VA Health Care System, Prescott, AZ 

Glossary 

C&P credentialing and privileging 

CAP Combined Assessment Program 

CBOC community based outpatient clinic 

CHF congestive heart failure 

CLC community living center 

COC coordination of care 

CT computed tomography 

ED emergency department 

EOC environment of care 

facility Northern Arizona VA Health Care System 

FTE full-time employee equivalents 

FY fiscal year 

ISO information security officer 

JC Joint Commission 

MDRO multidrug-resistant organisms 

OIG Office of Inspector General 

OSHA Occupational Safety and Health Administration 

QM quality management 

SOPs standard operating procedures 

VHA Veterans Health Administration 

VISN Veterans Integrated Service Network 

VA OIG Office of Healthcare Inspections 
CAP Review of the Northern Arizona VA Health Care System, Prescott, AZ 

Table of Contents 

Page
 

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

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

Objectives ............................................................................................................... 1
 

Scope...................................................................................................................... 1
 

Results ........................................................................................................................ 2
 

Review Activities With Recommendations .............................................................. 2
 

QM..................................................................................................................... 2
 

EOC................................................................................................................... 2
 

COC .................................................................................................................. 3
 

Management of Test Results............................................................................. 4
 

Management of MDRO...................................................................................... 5
 

Review Activity Without Recommendations............................................................ 6
 

Physician C&P................................................................................................... 6
 

Comments................................................................................................................... 6
 

Appendixes 

A. Facility Profile .................................................................................................... 7
 

B. Follow-Up on Previous Recommendations........................................................ 8
 

C. VHA Satisfaction Surveys and Hospital Outcome of Care Measures................ 9
 

D. VISN Director Comments .................................................................................. 11
 

E. Interim Facility Director Comments.................................................................... 12
 

F. OIG Contact and Staff Acknowledgments ......................................................... 18
 

G. Report Distribution ............................................................................................ 19
 

VA OIG Office of Healthcare Inspections 
Executive Summary: Combined Assessment Program 

Review of the Northern Arizona VA Health Care System, 

Prescott, AZ 

Review Purpose: The purpose was 

to evaluate selected activities, focusing 

on patient care administration and 

quality management, and to provide 

crime awareness training. We 

conducted the review the week of 

November 29, 2010. 

Review Results: The review covered 

six activities. We made no 

recommendations in the following 

activity: 

	 Physician Credentialing and 

Privileging 

Recommendations: We made 

recommendations in the following five 

activities: 

Quality Management: Strengthen 

processes to ensure that the review of 

the major organ systems is completed 

prior to sedation. 

Environment of Care: Ensure that only 

sharps items are disposed of in sharps 

containers. Complete and document 

annual N95 respirator fit testing. 

Coordination of Care: Ensure that staff 

document advance care planning 

discussion using approved progress 

note titles and that written discharge 

instructions address the patient’s activity 

level. 

Management of Test Results: Ensure 

diagnostic clinicians consistently 

document the time and the means by 

which critical test results are 

communicated to ordering providers. 

Require ordering providers to document 

patient notification and treatment actions 

in response to critical results. 

Periodically monitor the process of 

communicating pathology test results to 

providers and patients. 

Management of Multidrug-Resistant 

Organisms: Provide infection prevention 

strategies education to patients infected 

or colonized with multidrug-resistant 

organisms and their families and 

document it. 

Comments 

The Veterans Integrated Service 

Network and Interim Facility Directors 

agreed with the Combined Assessment 

Program review findings and 

recommendations and provided 

acceptable improvement plans. 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 OIG Office of Healthcare Inspections i 
CAP Review of the Northern Arizona VA Health Care System, Prescott, AZ 

Objectives and Scope 

Objectives
 

Scope
 

CAP reviews are one element of the OIG’s efforts to ensure 

that our Nation’s veterans receive high quality VA health care 

services. The objectives of the CAP review are to: 

	 Conduct recurring evaluations of selected health care 

facility operations, focusing on patient care administration 

and QM. 

	 Provide crime awareness briefings to increase employee 

understanding of the potential for program fraud and the 

requirement to refer suspected criminal activity to the 

OIG. 

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 selected areas, 

interviewed managers and employees, and reviewed clinical 

and administrative records. The review covered the 

following six activities: 

	 COC 

	 EOC 

	 Management of MDRO 

	 Management of Test Results 

	 Physician C&P 

	 QM 

The review covered facility operations for FY 2010 and 

FY 2011 through November 29, 2010, and was done in 

accordance with OIG SOPs for CAP reviews. 

We also followed up on selected recommendations from our 

prior CAP review of the facility (Combined Assessment 

Program Review of the Northern Arizona VA Health Care 

System, Prescott, Arizona, Report No. 08-02986-67, 

VA OIG Office of Healthcare Inspections 1 
CAP Review of the Northern Arizona VA Health Care System, Prescott, AZ 

February 5, 2009). The facility had corrected all prior 

findings. (See Appendix B for further details.) 

During this review, we also presented crime awareness 

briefings for 326 employees. These briefings covered 

procedures for reporting suspected criminal activity to the 

OIG and included case-specific examples illustrating 

procurement fraud, conflicts of interest, and bribery. 

In this report, we make recommendations for improvement. 

Recommendations pertain to issues that are significant 

enough to be monitored by the OIG until corrective actions 

are implemented. 

Results 

Review Activities With Recommendations 

QM	 The purpose of this review was to determine whether the 

facility had a comprehensive QM program in accordance with 

applicable requirements and whether senior managers 

actively supported the program’s activities. 

We interviewed senior managers and QM personnel, and we 

evaluated policies, meeting minutes, and other relevant 

documents. We identified the following area that needed 

improvement. 

Moderate Sedation. VHA requires that a pre-sedation 

assessment, which includes a review of the major organ 

systems, is performed prior to administration of moderate 

sedation.1 We reviewed the medical records of 10 patients 

who underwent moderate sedation and found that 

3 (30 percent) had no documented evidence of pre-sedation 

assessments of the heart and lungs. 

Recommendation	 1. We recommended that processes be strengthened to 

ensure that the review of the major organ systems is 

completed prior to sedation. 

EOC	 The purpose of this review was to determine whether the 

facility maintained a safe and clean health care environment 

in accordance with applicable requirements. 

We inspected the medical (4A), intensive care (4B), and CLC 

inpatient units; the domiciliary; the outpatient surgery (2A) 

and endoscopy suites; the laboratory and imaging 

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

VA OIG Office of Healthcare Inspections 2 
CAP Review of the Northern Arizona VA Health Care System, Prescott, AZ 

Recommendations 

COC 

departments (CT scan, general radiology, nuclear medicine, 

and ultrasound); the primary care and dental clinics; and the 

ED. The facility maintained a generally clean and safe 

environment. In the CLC-1 unit, we found two expired 

multi-dose medication vials. Managers immediately removed 

the expired medications. Therefore, we did not make a 

recommendation for this finding. However, we identified the 

following conditions that needed improvement. 

Waste Disposal. Local policies and state regulations define 

infectious (bio-hazardous) waste and sharps waste. 

According to recent facility guidelines on disposal of 

bio-hazardous waste, due to the high cost of sharps waste 

disposal, only certain medical sharps items (for example, 

contaminated needles, syringes, and scalpel blades) are to 

be disposed of in sharps containers. We found that sharps 

containers in several locations (2A, 4A, 4B, the primary care 

clinic, and radiology) contained non-medical sharps waste 

(such as urinals, empty intravenous bottles, and paper 

wrappers). These items should have been disposed of as 

regular waste. 

N95 Respirator Fit Testing. For facilities using N95 

respirators, OSHA standards require designated staff to be fit 

tested and trained annually for respirator use. We reviewed 

32 designated employees’ training records and determined 

that 7 (22 percent) employees had not received the required 

annual fit testing. 

2. We recommended that only sharps items be disposed of 

in sharps containers. 

3. We recommended that annual N95 respirator fit testing 

be completed and documented. 

The purpose of this review was to evaluate whether the 

facility managed advance care planning, advance directives, 

and discharges in accordance with applicable requirements. 

We reviewed patients’ medical records for evidence of 

advance care planning, advance directives, and discharge 

instructions. We found a consistent notification and 

screening process for advance directives. However, we 

noted that local policy did not identify the staff responsible for 

notifying and screening patients for advance directives. 

While we were onsite, managers agreed to update the local 

policy. Therefore, we did not make a recommendation for 

VA OIG Office of Healthcare Inspections 3 
CAP Review of the Northern Arizona VA Health Care System, Prescott, AZ 

this finding. We identified the following areas that needed 

improvement. 

Advance Care Planning Progress Note Titles. VHA requires 

that staff use specific progress note titles when documenting 

advance care planning discussions with patients.2 We 

reviewed advance care planning documentation for 

10 patients and determined that the facility did not use the 

required progress note titles in any of the medical records. 

Discharge Instructions. VHA requires the facility to provide 

discharge instructions to patients regarding medications, 

diet, activity level, and follow-up appointments.3 We 

reviewed documentation for 10 discharged patients and 

found that only 7 (70 percent) of the medical records 

addressed activity levels in the discharge instructions. 

Recommendations	 4. We recommended that staff document patient advance 

care planning discussions using approved progress note 

titles. 

5. We recommended that discharge instructions address 

the patient’s activity level. 

Management of	 The purpose of this review was to follow up on a previous 

Test Results evaluation that identified improvement opportunities related 

to documentation of notification of abnormal test results and 

follow-up actions taken.4 

We reviewed the facility’s policies and procedures, and we 

reviewed medical records. We identified the following areas 

that needed improvement. 

Documentation of Ordering Provider Notification. VHA 

requires that diagnostic (laboratory, radiology, and 

pathology) clinicians document in the medical record the time 

and means or method of critical test result communication 

and the name of the ordering provider contacted.5 We 

reviewed the medical records of 29 patients who had 

critical results. We found that diagnostic clinicians 

documented the time the ordering provider was notified in 

2 VHA Handbook 1004.02, Advance Care Planning and Management of Advance Directives, July 2, 2009.
 3 VHA Handbook 1907.01, Health Information Management and Health Records, August 25, 2006.
 4 Healthcare Inspection Summary Review – Evaluation of Veterans Health Administration Procedures for
 

Communicating Abnormal Test Results, Report No. 01-01965-24, November 25, 2002.
 5 VHA Directive 2009-019, Ordering and Reporting Test Results, March 24, 2009.
 

VA OIG Office of Healthcare Inspections 4 
CAP Review of the Northern Arizona VA Health Care System, Prescott, AZ 

Recommendations 

Management of 

MDRO 

only 20 (69 percent) records and the means of 

communication in only 15 (52 percent) records. 

Documentation of Treatment Actions. VHA requires ordering 

providers to document in the medical record patient 

notification and treatment actions in response to critical test 

results.6 We reviewed the medical records of 29 patients 

who had critical results and found documented evidence of 

patient notification and follow-up actions in only 

25 (86 percent) of the records. 

Monitoring Results Communication. VHA requires facilities 

to monitor the effectiveness of communication of results to 

providers and patients.7 We determined that radiology and 

the laboratory had established effective processes for 

monitoring communication of radiology and laboratory results 

to ordering providers. However, we did not find a similar 

process in anatomic pathology. Also, we did not find 

evidence that communication of pathology test results to 

patients was periodically monitored. 

6. We recommended that diagnostic clinicians consistently 

document the time of notification and the means by which 

critical results were communicated to ordering providers. 

7. We recommended that ordering providers document 

patient notification and treatment actions in response to 

critical results. 

8. We recommended that the process of communicating 

pathology test results to providers and patients be monitored 

periodically for effectiveness. 

The purpose of this review was to evaluate whether the 

facility had developed a safe and effective program to reduce 

the incidence of MDRO in its patient population in 

accordance with applicable requirements. 

We inspected the medicine and CLC inpatient units and 

interviewed three employees. We identified no deficits in 

either the inspections or staff interviews. However, we 

identified the following area that needed improvement. 

6 VHA Directive 2009-019. 

7 VHA Directive 2009-019. 

VA OIG Office of Healthcare Inspections 5 
CAP Review of the Northern Arizona VA Health Care System, Prescott, AZ 

Patient/Family Education. The JC requires that patients 

infected or colonized8 with MDRO and their families receive 

education on infection prevention strategies, such as hand 

washing and the proper use of personal protective 

equipment. We reviewed 10 medical records and found that 

6 (60 percent) of the records did not have documented 

evidence of MDRO education. 

Recommendation	 9. We recommended that infection prevention strategies 

education be provided to patients infected or colonized with 

MDRO and their families and that the education be 

documented. 

Review Activity Without Recommendations
 

Physician C&P	 The purpose of this review was to determine whether the 

facility had consistent processes for physician C&P that 

complied with applicable requirements. 

We reviewed C&P files and profiles and meeting minutes 

during which discussions about the physicians took place. 

We determined that the facility had implemented a consistent 

C&P process that met current requirements. We made no 

recommendations. 

Comments 

The VISN and Interim Facility Directors agreed with the CAP review findings and 

recommendations and provided acceptable improvement plans. (See Appendixes D 

and E, pages 11–17, for the full text of the Directors’ comments.) We will follow up on 

planned actions until they are completed. 

8 Colonization is the presence of bacteria in the body without causing clinical infection. 

VA OIG Office of Healthcare Inspections 6 
CAP Review of the Northern Arizona VA Health Care System, Prescott, AZ 

Appendix A 

Facility Profile9 

Type of Organization Primary and secondary health care 

system 

Complexity Level 3 

VISN 18 

CBOCs Anthem, AZ 

Cottonwood, AZ 

Bellemont, AZ 

Kingman, AZ 

Lake Havasu, AZ 

Veteran Population in Catchment Area 66,900 

Type and Number of Total Operating Beds: 

 Hospital 25 

 CLC/Nursing Home Care Unit 85 

 Domiciliary 120 

Medical School Affiliation(s) Western Medical, Phoenix, AZ 

 Number of Residents 2 

FY 2010 (through 

July 2010) 

Prior FY (2009) 

Resources (in millions): 

 Total Medical Care Budget $136.6 $129.9 

Total Medical Care FTE 855.4 828.2 

Workload: 

 Number of Station Level Unique Patients 23,263 23,837 

 Inpatient Days of Care: 

o Acute Care 6,507 8,226 

o CLC/Nursing Home Care Unit 22,180 24,864 

o Domiciliary 30,895 37,071 

Hospital Discharges 

o Acute Care 1,387 1,593 

o CLC/Nursing Home Care Unit 24 296 

o Domiciliary 321 382 

Total Average Daily Census (including all bed 

types) 

196.0 192.2 

Cumulative Occupancy Rate (including all bed 

types) 

85.4% 85.2% 

Outpatient Visits 232,971 259,025 

9 All data provided by facility management. 

VA OIG Office of Healthcare Inspections 7 
CAP Review of the Northern Arizona VA Health Care System, Prescott, AZ 

Appendix B 

Follow-Up on Previous Recommendations 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

Medication Management 

1. Track open action items until resolved. Tracking system for open items was 

developed and implemented. 

Y N 

2. Consistently include QM/performance 

improvement data in provider profiles for 

consideration at reprivileging. 

Ongoing Professional Practice 

Evaluation plans have been developed 

and implemented and maintained in 

provider profiles for reprivileging. 

Y N 

EOC 

3. Ensure the ISO participates in EOC 

rounds. 

ISO attendance is tracked. Y N 

4. Display suicide prevention posters and 

brochures in highly visible areas. 

Suicide prevention posters and 

brochures are posted throughout the 

facility. 

Y N 

5. Properly maintain storage areas, and 

secure sharp instruments. 

Supplies, including sharp instruments, 

are in locked storage areas. 

Y N 

6. Conduct more frequent ED EOC rounds, 

and address identified deficiencies. 

EOC checklists have been developed 

for the ED, routine inspections are 

conducted by ED staff, and any 

deficiencies are corrected. 

Y N 

VA OIG Office of Healthcare Inspections 8 
CAP Review of the Northern Arizona VA Health Care System, Prescott, AZ 

Appendix C 

VHA Satisfaction Surveys
 VHA has identified patient and employee satisfaction scores as significant indicators of 

facility performance. Patients are surveyed monthly. Table 1 below shows facility, 

VISN, and VHA overall inpatient and outpatient satisfaction scores and targets for 

quarters 1–3 of FY 2010. 

Table 1 

FY 2010 

(inpatient target = 64, outpatient target = 56) 

Inpatient 

Score 

Quarter 1 

Inpatient 

Score 

Quarter 1 

Inpatient 

Score 

Quarter 1 

Inpatient 

Score 

Quarter 1 

Inpatient 

Score 

Quarter 1 

Inpatient 

Score 

Quarter 1 

Facility 61.8 69.8 72.2 48.3 56.6 50.9 

VISN 65.0 63.3 64.2 52.2 52.7 53.1 

VHA 63.3 63.9 64.5 54.7 55.2 54.8 

Employees are surveyed annually. Figure 1 below shows the facility’s overall employee 

scores for 2008, 2009, and 2010. Since no target scores have been designated for 

employee satisfaction, VISN and national scores are included for comparison. 

0.0 

0.5 

1.0 

1.5 

2.0 

2.5 

3.0 

3.5 

4.0 

4.5 

5.0 

2008 2009 2010 

Facility 

VISN 

National 

VA ALL EMPLOYEE SURVEY 

OVERALL SATISFACTION Figure 1: 

LEVEL OF SATISFACTION 

VA OIG Office of Healthcare Inspections 9 
CAP Review of the Northern Arizona VA Health Care System, Prescott, AZ 

Hospital Outcome of Care Measures
 Hospital Outcome of Care Measures show what happened after patients with certain 

conditions10 received hospital care. The mortality (or death) rates focus on whether 

patients died within 30 days of their hospitalization. The rates of readmission focus on 

whether patients were hospitalized again within 30 days. Mortality rates and rates of 

readmission show whether a hospital is doing its best to prevent complications, teach 

patients at discharge, and ensure patients make a smooth transition to their home or 

another setting. The hospital mortality rates and rates of readmission are based on 

people who are 65 and older. These comparisons are “adjusted” to take into account 

their age and how sick patients were before they were admitted to the VA facility. 

Table 2 below shows the facility’s Hospital Outcome of Care Measures for 

FYs 2006–2009. 

Table 2 

Mortality Readmission 

Heart Attack CHF Pneumonia Heart Attack CHF Pneumonia 

Facility 12.14 12.94 14.96 0 20.2 15.4 

VHA 13.31 9.73 15.08 20.57 21.71 15.85 

10 CHF is a weakening of the heart’s pumping power. With heart failure, your body does not get enough oxygen and 

nutrients to meet its needs. A heart attack (also called acute myocardial infarction) happens when blood flow to a 

section of the heart muscle becomes blocked and the blood supply is slowed or stopped. If the blood flow is not 

restored in a timely manner, the heart muscle becomes damaged from lack of oxygen. Pneumonia is a serious lung 

infection that fills your lungs with mucus and causes difficulty breathing, fever, cough, and fatigue. 

VA OIG Office of Healthcare Inspections 10 
CAP Review of the Northern Arizona VA Health Care System, Prescott, AZ 

Appendix D 

VISN Director Comments 

Department of 

Veterans Affairs Memorandum 

Date:	 January 24, 2011 

From:	 Director, VISN 18 (10N18) 

Subject:	 CAP Review of the Northern Arizona VA Health Care 

System, Prescott, AZ 

To:	 Director, Los Angeles Healthcare Inspections Division 

(54LA) 

Director, Management Review Service (VHA CO 10B5 Staff) 

1. I concur with the attached facility draft responses to the 

recommendations for improvement contained in the Combined 

Assessment Program Review of the Northern Arizona VA Health Care 

System (NAVAHCS). 

2. If you have additional questions or concerns, please contact 

Sally Compton, VISN 18 Executive Assistant to the Network Director, at 

(602) 222-2699. 

(original signed by:) 

Susan P. Bowers 

VA OIG Office of Healthcare Inspections 11 
CAP Review of the Northern Arizona VA Health Care System, Prescott, AZ 

Appendix E 

Interim Facility Director Comments 

Department of 

Veterans Affairs Memorandum 

Date:	 January 21, 2011 

From:	 Interim Director, Northern Arizona VA Health Care System 

(649/00) 

Subject:	 CAP Review of the Northern Arizona VA Health Care 

System, Prescott, AZ 

To:	 Director, Los Angeles Healthcare Inspections Division 

(54LA) 

Network Director, VISN 18 (10N18) 

1.	 I have reviewed and concur with the findings and recommendations in 

the draft report of the Office of the Inspector General Combined 

Assessment Program Review conducted the week of 

November 29, 2010. 

2.	 Corrective action plans have been established with target completion 

dates, as detailed in the attached report. 

(original signed by:) 

Wendy J. Hepker, FACHE 

VA OIG Office of Healthcare Inspections 12 
CAP Review of the Northern Arizona VA Health Care System, Prescott, AZ 

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 processes be strengthened to ensure that 

the review of the major organ systems is completed prior to sedation. 

Concur. 

Target date for completion: February 1, 2011 

Planned Action: To ensure completion of pre-sedation assessments and review of the 

major organ systems prior to sedation, the following actions are being taken. A 

Standard Operating Procedure, History and Physical Examinations for Patients 

Receiving an Invasive Procedure, has been completed and reviewed with clinicians 

performing invasive procedures with moderate sedation. A CPRS template, 

Pre-Moderate Sedation Note, has been developed to include all required pre-sedation 

assessment elements. The Invasive Procedure Committee will add the required 

pre-sedation elements to the data collection and tracking process and a sample of 

10 records/month or 100% if the number of procedures is less than 10/month will be 

reviewed until a benchmark of 90% is achieved. After three months of achieving the 

benchmark, review of the pre-sedation elements will continue quarterly for one year. 

The Invasive Procedures Committee will report the outliers and action plan to the 

Medical Executive Board. 

Recommendation 2. We recommended that only sharps items be disposed of in 

sharps containers. 

Concur. 

Target date for completion: March 15, 2011 

Planned Action: To ensure staff knowledge and compliance with appropriate use of 

sharps containers, the following actions are being taken. A reference listing of items 

that are appropriate for sharps containers will be created and distributed. Assessment 

of compliance with appropriate use of sharps containers will be completed and 

documented during Environment of Care (EOC) Rounds. Findings will be reported to 

the EOC Board monthly until a benchmark of 90% is achieved for each unit. Once a 

unit achieves the benchmark, quarterly assessments will be performed. 

VA OIG Office of Healthcare Inspections 13 
CAP Review of the Northern Arizona VA Health Care System, Prescott, AZ 

Recommendation 3. We recommended that annual N95 respirator fit testing be 

completed and documented. 

Concur. 

Target date for completion: March 1, 2011 

Planned Action: To ensure the completion and documentation of annual N95 fit 

testing and training for designated staff, the following actions are being taken. A listing 

of employees with overdue fit testing was distributed to their supervisors on 

January 12 and 13, 2011. A weekly audit of overdue fit testing will be performed by the 

Employee Health Practitioner beginning January 24, 2011 with monthly reporting to the 

EOC Board until a benchmark of 100% is achieved. Once benchmark is achieved, 

monthly audits will be performed for three months and if benchmarks continue to be 

maintained, audit frequency will be reduced to quarterly. A listing of employees due for 

fit testing will be distributed to Service Line Managers at the first of each month. An 

addendum to Health Care System Memorandum 138-39, Respirator Program for 

Employees, will be published defining clear expectations for compliance with fit testing 

and consequences of not completing fit testing, as required. 

Recommendation 4. We recommended that staff document patient advance care 

planning discussions using approved progress note titles. 

Concur. 

Target date for completion: March 31, 2011 

Planned Action: To ensure compliance with the use of approved progress note titles 

when documenting patient advance care planning discussions, the following actions are 

being taken. The Computerized Patient Record System (CPRS) documentation tools 

were updated to reflect the requirements of VHA Handbook 1004.02, Advanced Care 

Planning and Management of Advance Directives. CPRS note titles have been 

amended and will be communicated to appropriate staff and training scheduled to be 

completed and fully implemented by Social Work, Acute Care Nursing, and Geriatric 

and Extended Care (GEC) Nursing by February 28, 2011. This documentation element 

will be added to monthly chart audits conducted by Acute Care and GEC Service Line 

Managers using a sample of 10 records/month or 100% if the number of admissions is 

less than 10/month for each Service Line. The data will be reported monthly to the 

Medical Records Committee and the Quality and Performance Board until a benchmark 

of 90% is achieved. After three months of achieving the benchmark, review and 

reporting of the data will continue quarterly for one year. 

VA OIG Office of Healthcare Inspections 14 
CAP Review of the Northern Arizona VA Health Care System, Prescott, AZ 

Recommendation 5. We recommended that discharge instructions address the 

patient’s activity level. 

Concur. 

Target date for completion: March 31, 2011 

Planned Action: To ensure patient discharge instructions include the patient’s activity 

level, the following actions are being taken. Activity level instructions were added to the 

Nursing Discharge Note CPRS template and will be communicated to appropriate staff 

and training scheduled to be completed and fully implemented by Acute Care Nursing 

and GEC Nursing staff at discharge by January 31, 2011. This documentation element 

will be added to monthly chart audits conducted by Acute Care and GEC Service Line 

Managers using a sample of 10 records/month or 100% if the number of discharges is 

less than 10/month for each Service Line. After three months of achieving a 

90% benchmark, review and reporting of documentation of patient activity level as an 

element of discharge instructions will continue quarterly for one year. The data will be 

reported quarterly to the Medical Records Committee and the Quality and Performance 

Board. 

Recommendation 6. We recommended that diagnostic clinicians consistently 

document the time of notification and the means by which critical results were 

communicated to ordering providers. 

Concur. 

Target date for completion: March 1, 2011 

Planned Action: To ensure that diagnostic clinicians consistently document the time of 

notification and the means by which critical results were communicated to ordering 

providers, the following actions are being taken. The Medical Center Policy, 

Communication of Patient Test Results, will be revised to include all aspects of 

notification of test results to include means or method of communication as well as 

documentation of date, time, and name of contacted provider. The revised policy will be 

communicated to appropriate staff and training scheduled to be completed and fully 

implemented by diagnostic clinicians by March 1, 2011. These documentation elements 

will be monitored and reported to the Medical Executive Board by monthly chart audits 

conducted by the Specialty Care Service Line Manager using a sample of 

10 records/month or 100% if the number of notifications is less than 10/month, until a 

benchmark of 90% is achieved. After three months of achieving the benchmark, review 

and reporting of the documentation elements will continue quarterly for one year. 

Recommendation 7. We recommended that ordering providers document patient 

notification and treatment actions in response to critical results. 

Concur. 

Target date for completion: April 10, 2011 

VA OIG Office of Healthcare Inspections 15 
CAP Review of the Northern Arizona VA Health Care System, Prescott, AZ 

Planned Action: To ensure that ordering providers document patient notification and 

treatment actions in response to critical results, the following actions are being taken. 

The ordering provider will document the acknowledgement of the receipt of the critical 

result, the medical provider’s assessment, plan, and patient notification in CPRS. The 

elements of documentation/template will be communicated to/training completed and 

fully implemented by the ordering providers by April 10, 2011. The documentation 

elements will be monitored and reported to the Medical Executive Board using monthly 

chart audits conducted by the Primary Care and Specialty Service Line Managers using 

a sample of 10 records/month or 100% by each Service Line if the number of critical 

results is less than 10/month until a benchmark of 90% is achieved. After three months 

of achieving the benchmark, review and reporting of the documentation elements will 

continue quarterly for one year. 

Recommendation 8. We recommended that the process of communicating pathology 

test results to providers and patients be monitored periodically for effectiveness. 

Concur. 

Target date for completion: April 1, 2011 

Planned Action: To ensure the process of communicating pathology test results to 

providers and patients are monitored for effectiveness, the following actions are being 

taken. The process of communicating pathology test results to providers and patients 

will be monitored by the Specialty Service Line Manager and reported to the Medical 

Executive Board using a sample of 10 records/month or 100% if the number of 

pathology test results is less than 10/month until a benchmark of 90% is achieved. After 

three months of achieving the benchmark, review and reporting of the documentation 

elements will continue quarterly for one year. 

Recommendation 9. We recommended that infection prevention strategies education 

be provided to patients infected or colonized with MDRO and their families and that the 

education be documented. 

Concur. 

Target date for completion: March 1, 2011 

Planned Action: To ensure that patients infected or colonized with MDRO and their 

families receive education on infection prevention strategies and that this education is 

documented, the following actions are being taken. A patient/family education template 

will be designed by the MDRO Prevention Coordinator to document the education 

provided to patients infected or colonized with MDRO and their families on infection 

prevention strategies. The elements of documentation/template will be communicated 

to the nurse managers on each unit by February 14, 2011. Training will be completed 

and the education template fully implemented by Acute Care and GEC Nursing staff by 

March 1, 2011. Completion of the template will be monitored by monthly chart audits 

using a sample of 10 records/month or 100% if the number of newly infected/colonized 

patients is less than 10/month until a benchmark of 90% is achieved. The results will be 

VA OIG Office of Healthcare Inspections 16 
CAP Review of the Northern Arizona VA Health Care System, Prescott, AZ 

reported monthly to the Medical Records Committee with outliers and action plan 

reported to the Quality & Performance Board. After three months of achieving the 

benchmark, review and reporting will continue quarterly for one year. 

VA OIG Office of Healthcare Inspections 17 
CAP Review of the Northern Arizona VA Health Care System, Prescott, AZ 

Appendix F 

OIG Contact and Staff Acknowledgments 

Contact Daisy Arugay, Director 

Los Angeles Office of Healthcare Inspections 

Contributors Douglas Henao, Team Leader 

Sheila Bezak 

Deborah Howard 

Judy Montano 

Simonette Reyes 

Kathleen Shimoda 

Mary Toy 

Richard Cady, Office of Investigations 

VA OIG Office of Healthcare Inspections 18 
CAP Review of the Northern Arizona VA Health Care System, Prescott, AZ 

Appendix G 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VA Southwest Health Care Network (10N18) 

Interim Director, Northern Arizona VA Health Care System (649/00) 

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: Jon Kyl, John McCain 

U.S. House of Representatives: Jeff Flake, Trent Franks, Gabrielle Giffords, 

Paul R. Gosar, Raul M. Grijalva, Ed Pastor, Ben Quayle, David Schweikert 

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

VA OIG Office of Healthcare Inspections 19