Department of Veterans Affairs 

Office of Inspector General 

Office of Healthcare Inspections
 

Report No. 10-02994-103 

Combined Assessment Program
 

Review of the
 

John J. Pershing VA Medical Center
 

Poplar Bluff, Missouri
 

February 24, 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 John J. Pershing VA Medical Center, Poplar Bluff, MO 

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 

CRC Cardiopulmonary Resuscitation Committee 

CSC Clinical Safety Committee 

CWAD Crisis, Warning, Allergies and/or Adverse Reactions, 

and Directives 

EOC environment of care 

facility John J. Pershing VA Medical Center 

FMS Facility Management Services 

FTE full-time employee equivalents 

FY fiscal year 

IC infection control 

JC Joint Commission 

MDRO multidrug-resistant organisms 

MH mental health 

MSDS material safety data sheet 

NFPA National Fire Protection Association 

OIG Office of Inspector General 

OSHA Occupational Safety and Health Administration 

PC primary care 

PI performance improvement 

PRRTP Psychosocial Residential Rehabilitation Treatment 

Program 

QM quality management 

RCA root cause analysis 

SOPs standard operating procedures 

UC urgent care 

VHA Veterans Health Administration 

VISN Veterans Integrated Service Network 

VA OIG Office of Healthcare Inspections 
CAP Review of the John J. Pershing VA Medical Center, Poplar Bluff, MO 

Table of Contents 

Page
 

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

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

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

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

Reported Accomplishments...................................................................................... 2
 

Results ........................................................................................................................ 3
 

Review Activities With Recommendations .............................................................. 3
 

Management of Test Results............................................................................. 3
 

QM..................................................................................................................... 4
 

COC .................................................................................................................. 5
 

EOC................................................................................................................... 6
 

Management of MDRO...................................................................................... 7
 

Review Activities Without Recommendations ......................................................... 8
 

Physician C&P................................................................................................... 8
 

Medication Management ................................................................................... 8
 

Comments................................................................................................................... 8
 

Appendixes 

A. Facility Profile .................................................................................................... 9
 

B. Follow-Up on Previous Recommendations........................................................ 10
 

C. VHA Satisfaction Surveys and Hospital Outcome of Care Measures................ 11
 

D. VISN Director Comments .................................................................................. 13
 

E. Facility Director Comments ............................................................................... 14
 

F. OIG Contact and Staff Acknowledgments ......................................................... 19
 

G. Report Distribution ............................................................................................ 20
 

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

Review of the John J. Pershing VA Medical Center, 

Poplar Bluff, MO 

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 15, 2010. 

Review Results: The review covered 

seven activities. We made no 

recommendations in the following 

activities: 

	 Physician Credentialing and 

Privileging 

	 Medication Management 

The facility’s reported accomplishments 

were reduced readmission rates for 

mental health patients, reduced fee 

based care expenditures, and enhanced 

veterans outreach programs. 

Recommendations: We made 

recommendations in the following five 

activities: 

Management of Test Results: Clearly 

define critical radiological results 

requiring prompt provider notification, 

monitor documentation of 

communication of critical radiology 

results to providers and patients, and 

consistently communicate normal 

radiological results to patients within the 

specified timeframe. 

Quality Management: Review current 

medications and drug allergies prior to 

procedures requiring moderate 

sedation, and monitor compliance. 

Review resuscitation events for 

performance improvement opportunities. 

Coordination of Care: Conduct and 

document screening for advance 

directives at admission, and monitor 

compliance. Document advance care 

planning using approved progress note 

titles, and monitor compliance. 

Environment of Care: Analyze infection 

control data, and report performance 

improvement actions to the appropriate 

committee. Complete and document 

annual N95 respirator fit testing and 

bloodborne pathogens training. 

Management of Multidrug-Resistant 

Organisms: Ensure employees receive 

annual multidrug-resistant organisms 

education, and document the training. 

Comments 

The Veterans Integrated Service 

Network and Facility Directors agreed 

with the Combined Assessment 

Program review findings and 

recommendations and provided 

acceptable improvement plans. 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 OIG Office of Healthcare Inspections i 
CAP Review of the John J. Pershing VA Medical Center, Poplar Bluff, MO 

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 seven activities: 

	 COC 

	 EOC 

	 Management of MDRO 

	 Management of Test Results 

	 Medication Management 

	 Physician C&P 

	 QM 

The review covered facility operations for FY 2009, FY 2010, 

and FY 2011 through November 15, 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 John J. Pershing VA Medical Center, 

Poplar Bluff, Missouri, Report No. 07-02837-83, 

VA OIG Office of Healthcare Inspections 1 
CAP Review of the John J. Pershing VA Medical Center, Poplar Bluff, MO 

February 26, 2008). The facility had corrected all findings. 

(See Appendix B for further details.) 

During this review, we also presented crime awareness 

briefings to 95 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. 

Reported Accomplishments 

The facility implemented a tele-discharge planning process 

for the discharge of their MH patients from the St. Louis VA 

Medical Center MH inpatient unit. More than 150 patients 

have been discharged using this new process. As a result, 

readmission rates for MH patients fell from 11.76 percent in 

January 2010 to 6.67 percent in July 2010. The VA Office of 

Rural Health identified this process, which is a collaborative 

effort and the first of its kind in the VISN, as a best practice. 

During FY 2010, the facility reduced its fee based care costs 

by 25 percent even though its service area is a highly rural 

environment. The facility also implemented a sleep study 

center that will significantly reduce costs for this service. The 

sleep study center alone will result in $1.1 million annual cost 

savings and will improve wait times for this service. This is 

expected to significantly improve patient satisfaction in this 

area. 

During FY 2010, facility leadership joined the Greater 

St. Louis Federal Executive Board and greatly expanded its 

outreach programs by participating in more than 50 local 

events. The facility developed and implemented new 

marketing and communication tools and gave formal 

presentations to the local Rotary Club, Kiwanis Club, and 

Chamber of Commerce. As a result, there were 

1,873 unique patients enrolled in FY 2010, and the facility’s 

market penetration rate increased to 45 percent, one of the 

highest in the country. The facility also expanded outreach 

to women veterans by participating in at least 20 women’s 

health events in FY 2010. 

Reduced 

Readmission Rates 

for MH Patients 

Reduced Fee 

Based Care 

Expenditures 

Enhanced Veterans 

Outreach 

VA OIG Office of Healthcare Inspections 2 
CAP Review of the John J. Pershing VA Medical Center, Poplar Bluff, MO 

The Help Hospitalized Veterans program selected the facility 

to host a Valentines for Veterans concert. Of the 17 sites 

selected, the facility was the only small rural facility to 

participate in the event. More than 3,000 veterans and their 

families were expected to attend at no charge. 

Results 

Review Activities With Recommendations 

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

Test Results review that identified improvement opportunities related to 

documentation of notification of abnormal test results and 

follow-up actions taken.1 

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

reviewed selected medical records. We also interviewed 

facility managers. We identified the following areas that 

needed improvement. 

Identification of Critical Radiology Results. For radiology test 

results, VA hospitals must define a critical result diagnostic 

code that is set by the radiologist at the time of report 

verification.2 The facility’s radiology software program did 

not include a critical result diagnostic code. Therefore, 

radiologists coded both critical results that required 

immediate attention and results that were abnormal but did 

not require immediate attention as “abnormal, attention 

needed.” To clarify the “abnormal, attention needed” 

diagnostic code, we reviewed the facility’s Abnormal 

Radiological Findings policy, which mandates prompt 

notification of abnormal “panic values” to the ordering 

physician. However, the policy did not clearly distinguish 

between critical results that would require prompt notification 

and abnormal results that would not require prompt 

notification. We were unable to fully evaluate the 

communication of critical radiology results because we were 

unable to distinguish true critical results from abnormal 

results. 

Monitoring Results Communication. VHA requires facilities 

to monitor the effectiveness of communication of tests results 

to providers and patients.3 We determined that the 

1 Healthcare Inspection Summary Review – Evaluation of Veterans Health Administration Procedures for
 

Communicating Abnormal Test Results, Report No. 01-01965-24, November 25, 2002.
 2 VA Radiology, “Online Guide,” <http://vaww1.va.gov/Radiology/page.cfm?pg=167>, updated
 

December 20, 2007, Sec. 3.3, Communication of Results.

3 VHA Directive 2009-019, Ordering and Reporting Test Results, March 24, 2009.
 

VA OIG Office of Healthcare Inspections 3 
CAP Review of the John J. Pershing VA Medical Center, Poplar Bluff, MO 

laboratory had established an effective process for 

monitoring communication of laboratory results to ordering 

providers. However, we did not find evidence that 

communication of radiology test results to providers and 

patients was periodically monitored. 

Communication of Normal Results. VHA requires facilities to 

communicate normal results to patients no later than 

14 calendar days from the date that the results were 

available to the ordering provider.4 We reviewed the medical 

records of 10 patients who had normal radiology results and 

found that only 8 (80 percent) of the 10 records contained 

documented evidence that the facility had communicated the 

results to the patients. 

Recommendations	 1. We recommended that the facility clearly define critical 

radiological results that require prompt notification of the 

ordering provider. 

2. We recommended that the facility monitor 

documentation of communication of critical radiology results 

to providers and patients. 

3. We recommended that normal radiology test results be 

consistently communicated to patients within the specified 

timeframe. 

QM	 The purpose of this review was to evaluate 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 areas that needed 

improvement. 

Moderate Sedation. VHA requires providers to document a 

complete history and physical within 30 days of a procedure 

and to re-evaluate the patient immediately prior to sedation.5 

These evaluations must include a review of drug allergies 

and current medications. We reviewed outpatient histories 

and physical examinations for a selection of procedures 

where moderate sedation was used and found that only 

4 VHA Directive 2009-019.
 5 VHA Directive 2006-023, Moderate Sedation by Non-Anesthesia Providers, May 1, 2006.
 

VA OIG Office of Healthcare Inspections 4 
CAP Review of the John J. Pershing VA Medical Center, Poplar Bluff, MO 

4 (40 percent) of 10 medical records contained current 

medications and drug allergy information. 

Resuscitation Outcomes. VHA requires that each facility 

have a policy mandating the membership and responsibilities 

of a CRC or its equivalent.6 This committee is responsible 

for review of individual cardiopulmonary arrests occurring at 

the facility as well as oversight review of aggregate data to 

identify and address any trends. While the Clinical Practice 

Council reviewed aggregate data for FY 2010, we found that 

the facility did not have a policy or a multidisciplinary 

committee to analyze each resuscitation event. During our 

onsite review, the facility revised the Code Blue Team policy 

and Clinical Patient Safety Committee charter to designate 

an equivalent CRC. 

Recommendations	 4. We recommended that current medications and drug 

allergies be reviewed prior to procedures requiring moderate 

sedation and that supervisors monitor for compliance. 

5. We recommended that each resuscitation event be 

reviewed by the designated CRC for PI opportunities. 

COC	 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 identified the following areas that needed 

improvement. 

Screening. VHA requires that at the time of each admission 

to a VHA inpatient facility, patients must be asked whether 

they have an advance directive or whether they want more 

information about advance directives and/or assistance in 

completing the advance directive forms.7 This screening 

must be documented in the patient’s health record. We 

found evidence of screening in initial nursing assessments 

for 17 (85 percent) of the 20 patient records we reviewed. 

Advance Care Planning Progress Note Titles. VHA requires 

that staff use specific progress note titles when documenting 

advance care planning discussions with patients and link 

6 VHA Directive 2008-063, Oversight and Monitoring of Cardiopulmonary Resuscitative Events and Facility
 

Cardiopulmonary Resuscitation Committees, October 17, 2008.
 7 VHA Handbook 1004.02, Advance Care Planning and Management of Advance Directives, July 2, 2009.
 

VA OIG Office of Healthcare Inspections 5 
CAP Review of the John J. Pershing VA Medical Center, Poplar Bluff, MO 

Recommendations 

EOC 

these notes to the CWAD posting in the electronic medical 

record.8 We reviewed advance care planning documentation 

for 16 patients and determined that the facility used the 

required progress note titles in 11 (69 percent) of the 

16 records. All notes were linked to the CWAD posting. The 

facility’s advance care planning policy had not been updated 

since the publication of VHA Directive 1004.02 and did not 

address the specific progress note titles. Senior leadership 

told us that the local policy was scheduled for review in 

December and assured us that revisions would address all 

required components. 

6. We recommended that screening regarding advance 

directives be conducted and documented at each inpatient 

admission and that supervisors monitor for compliance. 

7. We recommended that advance care planning be 

documented using approved progress note titles and that 

supervisors monitor for compliance. 

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 CLC; the inpatient medical unit; the dental, 

MH, and wound clinics; a PC/specialty clinic; Radiology 

Service; the UC area; and the outpatient laboratory and 

found that the facility maintained a generally clean and safe 

environment. 

We found that the MSDS inventory log in the UC area was 

outdated. While we were onsite, managers updated the 

MSDS inventory log. 

The JC and the NFPA require at least 18 inches of open 

space from the sprinkler deflector to the top of a storage unit. 

In the UC medication room, we found a shelf full of supplies 

located less than 18 inches below the sprinkler deflector. 

Managers removed the supplies immediately. Since these 

conditions were corrected while we were onsite, we made no 

recommendations for these findings. However, we identified 

the following conditions that needed improvement. 

IC. The JC requires that IC data be analyzed and that 

actions be prioritized, implemented, and reported. We 

reviewed IC Committee minutes for the 3rd and 4th quarter of 

8 VHA Handbook 1004.02. 

VA OIG Office of Healthcare Inspections 6 
CAP Review of the John J. Pershing VA Medical Center, Poplar Bluff, MO 

Recommendations 

Management of 

MDRO 

Recommendation 

FY 2010 and found that IC monitors were not analyzed for 

PI. 

OSHA requires that facilities using N95 respirators fit test 

designated employees annually. We reviewed the records of 

29 selected employees and determined that only 

4 (14 percent) of the 29 employees had the required annual 

fit testing. 

OSHA requires that all employees receive initial and annual 

training on the OSHA Bloodborne Pathogens Rule. We 

reviewed training records for 26 selected employees and 

found that 22 (85 percent) of the 26 employees had this 

training documented for FY 2010. 

8. We recommended that the IC program be strengthened 

to ensure that data is analyzed and that PI actions are 

reported to the appropriate committee. 

9. We recommended that annual N95 respirator fit testing 

and bloodborne pathogens training be completed and 

documented. 

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 CLC unit and interviewed employees. We 

identified no deficits in either the inspections or staff 

interviews. However, we identified the following area that 

needed improvement. 

Employee Training. The JC requires that facilities conduct a 

risk assessment to determine the need for staff education. 

The facility’s most recent risk assessment and the local IC 

policy stated that staff education was indicated for all 

employees during orientation and annually thereafter. We 

reviewed 35 employee training records to determine whether 

MDRO education had been completed. We found that 

4 (33 percent) of 12 clinical staff and 6 (26 percent) of 

23 FMS employees had no documentation of annual MDRO 

education. 

10. We recommended that employees receive annual 

MDRO education and that the training be documented. 

VA OIG Office of Healthcare Inspections 7 
CAP Review of the John J. Pershing VA Medical Center, Poplar Bluff, MO 

Review Activities 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 10 physicians’ 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. 

Medication	 The purpose of this review was to determine whether the 

Management facility employed safe practices in the preparation, transport, 

and administration of hazardous medications, specifically 

chemotherapy, in accordance with applicable requirements. 

We interviewed the Chief of Pharmacy and one registered 

nurse qualified to administer chemotherapy medications. We 

also reviewed the facility’s policy for handling chemotherapy 

medications. The facility did not have a patient on 

chemotherapy during our site visit; however, employees 

correctly described the steps for the preparation, 

transportation, and administration of chemotherapy 

medications. We made no recommendations. 

Comments 

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

recommendations and provided acceptable improvement plans. (See Appendixes D 

and E, pages 13–18, for the full text of the Directors’ comments.) We consider 

Recommendations 1 and 7 closed. We will follow up on the planned actions for the 

open recommendations until they are completed. 

VA OIG Office of Healthcare Inspections 8 
CAP Review of the John J. Pershing VA Medical Center, Poplar Bluff, MO 

Appendix A 

Facility Profile9 

Type of Organization Primary care veteran’s rural access to 

health care 

Complexity Level 3 

VISN 15 

CBOCs Cape Girardeau, MO 

Farmington, MO 

Sikeston, MO 

Salem, MO 

West Plains, MO 

Paragould, AR 

Veteran Population in Catchment Area 50,000 

Type and Number of Total Operating Beds: 

 Hospital, including PRRTP 18 

 CLC/Nursing Home Care Unit 40 

 Other 0 

Medical School Affiliation(s) None 

 Number of Residents 0 

FY 2010 (through 

August 2010) 

Prior FY (2009) 

Resources (in millions): 

 Total Medical Care Budget $68.9 $63.8 

 Medical Care Expenditures $68.9 $63.8 

Total Medical Care FTE 363 359 

Workload: 

 Number of Station Level Unique 

Patients 

18,826 17,975 

 Inpatient Days of Care: 

o Acute Care 4,874 5,132 

o CLC/Nursing Home Care Unit 8,695 10,133 

Hospital Discharges 1,367 medical 

153 CLC 

1,398 medical 

156 CLC 

Total Average Daily Census (including all bed 

types) 

40.5 41.2 

Cumulative Occupancy Rate 69.9% 71.1% 

Outpatient Visits 165,497 146,586 

9 All data provided by facility management. 

VA OIG Office of Healthcare Inspections 9 
CAP Review of the John J. Pershing VA Medical Center, Poplar Bluff, MO 

Appendix B 

Follow-Up on Previous Recommendations 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

QM 

1. Complete peer reviews within 120 days, 

and submit quarterly reports to the Medical 

Executive Committee. 

Peer reviews have been completed 

within required timeframes, and 

quarterly reports were submitted as 

required. 

Y N 

2. Ensure RCAs are completed within 

45 days. 

All RCAs have been completed within 

45 days for FYs 2009–2010. 

Y N 

3. Ensure that the PI Committee serves as 

oversight for all QM activities. 

The Executive PI Committee (formerly 

the PI Committee) oversees all QM 

activities. 

Y N 

Business Rules 

4. Update business rules to comply with 

VHA policy. 

Business rules comply with VHA policy. Y N 

VA OIG Office of Healthcare Inspections 10 
CAP Review of the John J. Pershing VA Medical Center, Poplar Bluff, MO 

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 2 

Inpatient 

Score 

Quarter 3 

Outpatient 

Score 

Quarter 1 

Outpatient 

Score 

Quarter 2 

Outpatient 

Score 

Quarter 3 

Facility 59.5 60.7 58.0 51.7 48.0 41.5 

VISN 59.0 56.0 56.9 53.5 52.9 51.6 

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. 

VA OIG Office of Healthcare Inspections 11 
CAP Review of the John J. Pershing VA Medical Center, Poplar Bluff, MO 

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 13.99 11.92 15.08 20.25 20.96 17.29 

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 12 
CAP Review of the John J. Pershing VA Medical Center, Poplar Bluff, MO 

Appendix D 

VISN Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: February 3, 2011 

From: Director, VA Heartland Network (10N15) 

Subject: CAP Review of the John J. Pershing VA Medical Center, 

Poplar Bluff, MO 

To: Director, Bay Pines Healthcare Inspections Division (54SP) 

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

I have reviewed and concur with the Medical Center Director’s response 

and action plan. 

(original signed by:) 

JAMES R. FLOYD, FACHE 

VA OIG Office of Healthcare Inspections 13 
CAP Review of the John J. Pershing VA Medical Center, Poplar Bluff, MO 

Appendix E 

Facility Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: February 1, 2011 

From: Director, John J. Pershing VA Medical Center (657A4/00) 

Subject: CAP Review of the John J. Pershing VA Medical Center, 

Poplar Bluff, MO 

To: Director, VA Heartland Network (10N15) 

1.	 We appreciate the opportunity to review the draft report for the 

John J. Pershing VA Medical Center in Poplar Bluff, Missouri. 

2.	 Attached, please find Poplar Bluff VA Medical Center’s response to the 

Office of Inspector General Combined Assessment Program 

(OIG-CAP) review conducted during the week of November 15, 2010. 

3.	 We would like to extend our appreciation to the Office of Inspector 

General Team that conducted the review; they were very professional 

and provided excellent feedback to our staff. We appreciate their 

thorough review and the opportunity to further improve the quality care 

we provide to our Veterans every day. 

4.	 If you have any questions regarding the information provided, please 

contact Dawna Bader, Director of Performance Improvement. 

Ms. Bader can be reached at (573) 778-4280. 

(original signed by:) 

GLENN A. COSTIE, FACHE 

Medical Center Director 

VA OIG Office of Healthcare Inspections 14 
CAP Review of the John J. Pershing VA Medical Center, Poplar Bluff, MO 

Comments to Office of Inspector General’s Report
 

The following Director’s comments are submitted in response to the recommendations 

in the Office of Inspector General report: 

OIG Recommendations 

Recommendation 1. We recommended that the facility clearly define critical 

radiological results that require prompt notification of the ordering provider. 

Facility Response: Concur with recommendation. 

Target Completion Date: Completed January 26, 2011. 

The facility revised its policy on reporting abnormal radiological test results to clearly 

define critical radiological results. The policy is being circulated for concurrences, and 

the identification and reporting of critical results have already been put into place 

according to the new policy’s guidance. Recommend closure of this item. 

Recommendation 2. We recommended that the facility monitor documentation of 

communication of critical radiology results to providers and patients. 

Facility Response: Concur with recommendation. 

Target Completion Date: June 30, 2011. 

The facility revised its policy on reporting abnormal radiological test results to clearly 

define critical radiological results and to outline the process for monitoring 

communication of critical results. Monitoring of critical radiological results began on 

January 25, 2011. Results from this monitor will be aggregated, analyzed, and reported 

to the CSC on a monthly basis in order to identify opportunities for improvement, and 

will be reduced to quarterly once the target of 90 percent is achieved and sustained. 

Recommendation 3. We recommended that normal radiology test results be 

consistently communicated to patients within the specified timeframe. 

Facility Response: Concur with recommendation. 

Target Completion Date: March 31, 2011 

A new process was implemented in December 2010 in a PC test clinic whereby a PC 

team member (clerk or licensed practical nurse) is notified by view alert to the normal 

laboratory and radiology results. Once the alert is received, the PC team member 

initiates and sends a letter on behalf of the patient’s PC Provider notifying the veteran of 

his/her normal test results and documents this action in the electronic health record. So 

far, this process has been effective in the test clinic and will be rolled out to the 

remaining PC clinics by March 31, 2011. Afterwards, a monthly chart review will be 

VA OIG Office of Healthcare Inspections 15 
CAP Review of the John J. Pershing VA Medical Center, Poplar Bluff, MO 

performed for every clinic and results reported through the Medical Records Committee 

until the target of 90 percent is achieved and sustained, after which the review will be 

conducted quarterly. 

Recommendation 4. We recommended that current medications and drug allergies be 

reviewed prior to procedures requiring moderate sedation and that supervisors monitor 

for compliance. 

Facility Response: Concur with recommendation. 

Target Completion Date: June 30, 2011. 

The facility revised its Licensed Independent Practitioner (LIP) pre-operative 

assessment template to include a required field for review of medications and allergies. 

The facility also revised its concurrent medical record review tool to include a section on 

documentation of medication and allergy review prior to administration of moderate 

sedation. This concurrent tool is used to review 100 percent of endoscopy cases. Staff 

began using the revised tool on February 1, 2011. Results from the concurrent review 

will be reported through the Surgical Quality Improvement Committee on a monthly 

basis in order to identify opportunities for improvement until the target of 90 percent is 

achieved and sustained, after which the review will be conducted quarterly. 

Recommendation 5. We recommended that each resuscitation event be reviewed by 

the designated CRC for PI opportunities. 

Facility Response: Concur with recommendation. 

Target Completion Date: Completed November 23, 2010. 

On November 16, 2010, the CSC charter was revised to include its delegated 

responsibility to act as the facility’s CRC. The CSC began quarterly case review of 

each individual resuscitation event with the first discussion occurring on 

November 23, 2010. In addition to this action, all cardiopulmonary resuscitation cases 

are reviewed and discussed in either the Morbidity and Mortality Committee or the Peer 

Review Committee as has been the practice for a number of years. Recommend 

closure of this item. 

Recommendation 6. We recommended that screening regarding advance directives 

be conducted and documented at each inpatient admission and that supervisors 

monitor for compliance. 

Facility Response: Concur with recommendation. 

Target Completion Date: June 30, 2011. 

Advance Directives (AD) screening and education is performed as part of the inpatient 

admission assessment and is monitored as part of the quarterly ongoing medical record 

review process. Due to the underperforming results, the supervisor provided education 

VA OIG Office of Healthcare Inspections 16 
CAP Review of the John J. Pershing VA Medical Center, Poplar Bluff, MO 

to Acute Care staff, and a random sample of medical records are being reviewed on a 

monthly basis to determine if AD screening and education was performed as required. 

Findings from this review will be reported to the Medical Record Committee until a 

target of 90 percent compliance is achieved and sustained, after which it will be moved 

to a quarterly monitor. 

Recommendation 7. We recommended that advance care planning be documented 

using approved progress note titles and that supervisors monitor for compliance. 

Facility Response: Concur with recommendation. 

Target Completion Date: Completed January 28, 2011. 

The VHA allows only three progress note titles for advance directives: Advance 

Directives, Advance Directive Discussions, and Rescinded Advance Directives. 

Because the facility is part of an integrated computer system with two other VA facilities, 

we could not incorporate a documentation template using these three notes, and a 

fourth progress note title, “Advance Directives – PB” was instituted, which allowed the 

incorporation of a documentation template. As a result of the OIG’s recommendation, 

on January 28, 2011, the progress note title “Advance Directives – PB” was inactivated 

and only the three allowed progress notes titles remain. Compliance with using only the 

allowed progress notes titles will be monitored as part of the ongoing medical record 

review (refer to facility response to recommendation 6). Since no other progress note 

title is available to staff, recommend closure of this item. 

Recommendation 8. We recommended that the IC program be strengthened to 

ensure that data is analyzed and that PI actions are reported to the appropriate 

committee. 

Facility Response: Concur with recommendation. 

Target Completion Date: Completed December 28, 2010. 

In October 2010, a new committee, the CSC, was formed, which was delegated to 

serve as the facility’s IC Committee. IC results and data analysis are presented on a 

monthly basis by the IC Nurse and the IC Physician, and the reports are submitted to 

the CSC who reviews the reports to identify opportunities for improvement. 

Recommend closure of this item. 

Recommendation 9. We recommended that annual N95 respirator fit testing and 

bloodborne pathogens training be completed and documented. 

Facility Response: Concur with recommendation. 

Target Completion Date: Fit-Testing will be completed by April 30, 2011. Training on 

Blood-borne Pathogens will be completed by September 30, 2011. 

VA OIG Office of Healthcare Inspections 17 
CAP Review of the John J. Pershing VA Medical Center, Poplar Bluff, MO 

A risk assessment identified 100 employees who need to be fit-tested for N-95 face 

masks according to the facility’s TB and IC Plans. The facility recently hired a full-time 

GEMS Coordinator who is an Industrial Hygienist and an OSHA Certified Fit Tester, and 

he will perform fit testing for all 100 N-95 users by April 30, 2011, and annually 

thereafter. Blood-borne Pathogens training is an annual training requirement for all 

staff, and is documented and tracked in LMS. The Education Department will run 

monthly reports by service and submit them to unit supervisors and service chiefs until 

100 percent compliance is achieved. These reports will also be submitted to the EOC 

Committee, who will track employee compliance in completing N-95 Fit Testing, and to 

the CSC (the facility’s IC Committee) who will track employee completion of Bloodborne Pathogens. 

Recommendation 10. We recommended that employees receive annual MDRO 

education and that the training be documented. 

Facility Response: Concur with recommendation. 

Target Completion Date: September 30, 2011. 

A presentation on Multiple Drug Resistant Organisms (MDRO) was developed and 

made available to staff on February 1, 2011. It will be completed by all staff (excluding 

administrative staff) and as part of new employee orientation beginning 

February 1, 2011, with required annual retraining for the same target employee group. 

Completion of MDRO training will be documented and tracked in LMS and reported by 

the IC Nurse on a monthly basis until the target of 95 percent is achieved and 

sustained. 

VA OIG Office of Healthcare Inspections 18 
CAP Review of the John J. Pershing VA Medical Center, Poplar Bluff, MO 

Appendix F 

OIG Contact and Staff Acknowledgments 

Contact Christa Sisterhen, Director 

Bay Pines Office of Healthcare Inspections 

Contributors David Griffith, Team Leader 

Bettye Burns 

Darlene Conde-Nadeau 

Kathy Gudgell 

Alice Morales-Rullan 

Annette Robinson 

Carol Torczon 

Idell Graham 

James Werner, Office of Investigations 

VA OIG Office of Healthcare Inspections 19 
CAP Review of the John J. Pershing VA Medical Center, Poplar Bluff, MO 

Appendix G 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VA Heartland Network (10N15) 

Director, John J. Pershing VA Medical Center (657A4/00) 

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: Roy Blunt, John Boozman, Claire McCaskill, Mark L. Pryor 

U.S. House of Representatives: Rick Crawford, Jo Ann Emerson 

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

VA OIG Office of Healthcare Inspections 20