Department of Veterans Affairs 

Office of Inspector General 

Combined Assessment Program 

Summary Report 

Re-Evaluation of Reusable Medical 

Equipment and Environment of Care 

at the Central Texas Veterans 

Health Care System 

Temple, Texas 

Report No. 10-03926-76 January 26, 2011

VA Office of Inspector General 

Washington, DC 20420 
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)
Re-Evaluation of RME and EOC at the Central Texas Veterans Health Care System, Temple, TX 

Executive Summary 

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

Healthcare Inspections completed a re-evaluation of reusable medical equipment (RME) 

and environment of care (EOC) at the Central Texas Veterans Health Care System (the 

facility), Temple, TX. The purposes of the re-evaluation were to determine whether the 

facility had comprehensive, effective reprocessing of RME and a safe and clean health 

care environment. 

The results of this re-evaluation indicated notable improvement in the RME and EOC 

areas cited for noncompliance in the Combined Assessment Program (CAP) review 

conducted by the OIG in March 2010. For RME, senior managers obtained a consultant 

to complete an organizational assessment of Supply, Processing, and Distribution and to 

implement improvements. Facility managers took immediate action to implement and 

correct many of the identified EOC deficiencies. However, further improvement is 

needed in both RME and EOC. We will follow up on all of the recommendations from 

the March CAP at the next scheduled CAP. Therefore, we made no new 

recommendations. 

The Veterans Integrated Service Network 17 and Facility Directors concurred with our 

conclusions. 

VA Office of Inspector General i 
DEPARTMENT OF VETERANS AFFAIRS

Office of Inspector General 

Washington, DC 20420 

TO: Veterans Integrated Service Network 17 Director (10N17) 

SUBJECT: Combined Assessment Program Summary Report – Re-Evaluation of 

Reusable Medical Equipment and Environment of Care at the Central 

Texas Veterans Health Care System, Temple, Texas 

Summary 

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

Healthcare Inspections completed a re-evaluation of reusable medical equipment (RME) 

and environment of care (EOC) at the Central Texas Veterans Health Care System (the 

facility), Temple, TX. The purposes of the re-evaluation were to determine whether the 

facility had comprehensive, effective reprocessing of RME and a safe and clean health 

care environment. 

The results of this re-evaluation indicated notable improvements in RME and EOC 

compared with the evaluation conducted by the OIG in March 2010. However, there 

were still opportunities to improve in both areas. For RME, the standard operating 

procedure (SOP) for the prostate biopsy probe needs to be consistent with the 

manufacturer’s instructions, and employees need to follow the manufacturer’s 

instructions for reprocessing colonoscopes. For EOC, we identified concerns with EOC 

rounds, respiratory fit testing, infection control (IC), and staff training. 

Background 

In March 1999, the OIG initiated Combined Assessment Program (CAP) reviews to 

provide recurring oversight of VA facility operations, focusing on the effectiveness and 

the quality of care and services provided to veterans. 

In March 2010, the OIG conducted a CAP review at the facility and identified problems 

in RME and EOC. Inspectors had three RME findings and six EOC findings. These 

substantial findings initiated this re-evaluation. 

VA Office of Inspector General 1 
Re-Evaluation of RME and EOC at the Central Texas Veterans Health Care System, Temple, TX 

VA Office of Inspector General 2 

Scope and Methodology 

We made an announced visit to the facility November 1–3, 2010. Our review focused on 

RME and EOC activities over the 7-month period from March through September 2010. 

To evaluate RME and EOC, we interviewed the facility’s Director, the Chief of Staff, 

selected service chiefs, and personnel. We also reviewed plans, policies, and other 

relevant documents. To evaluate RME, we inspected the decontamination, cleaning, and 

sterile storage areas within Supply, Processing, and Distribution (SPD). We also 

inspected the gastrointestinal (GI) reprocessing area. To evaluate EOC, we inspected 

patient care units, the emergency department, and outpatient clinics in Temple and Waco. 

We conducted the review in accordance with Quality Standards for Inspections published 

by the President’s Council on Integrity and Efficiency. 

Inspection Results 

Issue 1: RME 

The purpose of this review was to evaluate whether the facility had processes in place to 

ensure effective reprocessing of RME. Improper reprocessing of RME may transmit 

pathogens to patients and affect the functionality of the equipment. Veterans Health 

Administration (VHA) facilities are responsible for minimizing patient risk and 

maintaining a safe environment. The facility’s SPD and satellite reprocessing areas are 

required to meet VHA, Association for the Advancement of Medical Instrumentation, 

Occupational Safety and Health Administration (OSHA), and Joint Commission (JC) 

standards. 

We inspected the decontamination, cleaning, and sterile storage areas within SPD. We 

also inspected the GI satellite reprocessing area. We found substantial improvement 

overall in cleanliness. We reviewed the competency folders of 11 SPD employees and 

found that all annual competencies had been completed and correctly reflected 

manufacturers’ instructions. However, we identified the following area that required 

continued improvement. 

SOPs and Manufacturers’ Instructions. VHA policy1

 requires that device-specific SOPs 

for RME be established in accordance with manufacturers’ instructions. We reviewed 

the SOPs and manufacturers’ instructions for five pieces of RME. We found that the 

SOP for the prostate biopsy probe was not consistent with the manufacturer’s 

instructions. 

 

1

 VHA Directive 2009-031, Improving Safety in the Use of Reusable Medical Equipment through Standardization of 

Organizational Structure and Reprocessing Requirements, June 26, 2009. 
Re-Evaluation of RME and EOC at the Central Texas Veterans Health Care System, Temple, TX 

VA Office of Inspector General 3 

VHA policy2 also requires facilities to follow manufacturers’ instructions when 

reprocessing RME. Staff did not follow the manufacturer’s instructions when we 

observed them reprocessing the colonoscope. They did not correctly perform leak 

testing, which required angulations of the bending section, nor did they ensure that the 

colonoscope was soaked in the specified cleaning solution for the required time and at the 

appropriate temperature. The facility acknowledged these issues and took steps to correct 

them. Therefore, we made no new recommendations. 

Issue 2: EOC 

The purpose of this review was to determine whether the facility maintained a safe and 

clean health care environment. VHA facilities are required to establish a comprehensive 

EOC program that fully meets VHA, National Center for Patient Safety, OSHA, National 

Fire Protection Association, and JC standards. 

Based on the recommendations made in the CAP report, the facility made changes in the 

Environmental Management Service (EMS), which included assigning staff permanently 

to specific work areas and developing an EMS response team to resolve unexpected 

needs. This allowed permanently assigned staff to complete routine duties as scheduled. 

Overall, the facility was clean, and appropriate repairs had been made. This represented 

a notable improvement from the previous review. The facility had corrected previous 

findings regarding overall cleanliness, medication security, negative air flow room 

monitoring, Code Alert® system monitoring, oxygen storage, intensive care unit closet 

floor tiles, the fire exit door, audibility of call alarms on the inpatient units, patient 

auditory privacy in an outpatient clinic, and external cleaning of buildings at the Waco 

division. However, we found the following areas still in need of improvement. 

EOC Rounds. VHA policy3

 requires EOC rounds to be conducted by the facility’s 

inspection team to allow each discipline participating to identify and correct 

discrepancies, unsafe working conditions, and other regulatory violations. 

Representation from each discipline enables the team to cover the facility in depth. VHA 

policy also requires specific personnel to attend EOC rounds. For the period April 

through September 2010, we reviewed attendance for 42 bi-weekly EOC rounds for 

Temple and 32 bi-weekly EOC rounds for Waco. For the Temple division, the 

attendance rate on rounds was 5 percent for nursing management, 83 percent for building 

management, 31 percent for patient safety, 69 percent for IC, and 76 percent for the 

Information Security Officer (ISO). For the Waco division, the attendance rate on rounds 

was 53 percent for the Director or Associate Director, 47 percent for nursing 

management, 38 percent for patient safety, 56 percent for IC, and zero percent for the 

ISO. These numbers indicate little improvement in this area since our March visit. 

 

2

 VHA Directive 2009-031. 

3

 Deputy Under Secretary for Health for Operations and Management, “Environmental Rounds,” memorandum, 

March 5, 2007. 
Re-Evaluation of RME and EOC at the Central Texas Veterans Health Care System, Temple, TX 

Facility management acknowledged the issue and took steps to correct it. Therefore, we 

made no new recommendation. 

Respirator Fit Testing. OSHA requires that fit testing of any negative pressure respirator 

be completed at least annually for individuals identified as at risk. The facility uses 

N95 respirators to reduce exposure to harmful atmospheres for staff in high-risk areas. 

Nine (38 percent) of 24 selected direct care staff at risk for exposure did not receive the 

required fit testing. We noted improvement from our March visit finding and did not 

make a new recommendation. 

IC. The JC requires the facility to monitor key IC practices and implement appropriate 

actions when thresholds are not met. The minutes of the IC Committee identified issues 

such as hand hygiene, surgical infection rates, and compliance with immunizations. For 

example, the hand hygiene monitor identified that 11 (29 percent) of 38 areas were below 

the established 95 percent threshold. There were no individualized plans based on these 

issues or updates to the action items when the monitors showed no improvement. This 

finding was the same as in our March visit. Facility management acknowledged the issue 

and took steps to correct it. Therefore, we made no new recommendation. 

EMS Staff Training. Local policy requires EMS staff to receive annual training on 

cleaning and disinfection procedures. During our previous review, only 67 percent of 

EMS staff were compliant with required OSHA Bloodborne Pathogens Rule annual 

training. On this visit, all 10 of the EMS staff whose training records we reviewed had 

completed the required training. However, the facility was unable to provide 

documentation that showed that these 10 EMS staff had received annual cleaning and 

disinfection procedure training. This is a decrease from 28 percent from our March visit. 

Facility management acknowledged the issue and took steps to correct it. Therefore, we 

made no new recommendation. 

Conclusions 

We found notable improvement in the RME and EOC areas cited for noncompliance in 

the CAP report published July 9, 2010. Senior managers acknowledged the CAP 

findings and implemented several appropriate actions. Facility managers obtained a 

consultant to complete an organizational assessment of SPD and to implement 

improvements. They took action to implement and correct most of the EOC deficiencies. 

However, further improvement is needed in both RME and EOC. We will follow up on 

all of the recommendations from the March CAP at the next scheduled CAP. Therefore, 

we made no new recommendations. 

VA Office of Inspector General 4 
Re-Evaluation of RME and EOC at the Central Texas Veterans Health Care System, Temple, TX 

VA Office of Inspector General 5 

Comments 

The VISN and Facility Directors concurred with our conclusions. (See Appendixes 

A and B, pages 6–7, for the full text of the Directors’ comments.) 

 (original signed by:)

JOHN D. DAIGH, JR., M.D. 

Assistant Inspector General for 

Healthcare Inspections 
Re-Evaluation of RME and EOC at the Central Texas Veterans Health Care System, Temple, TX 

Appendix A 

VISN Director Comments 

VA Office of Inspector General 6 

Department of 

Veterans Affairs Memorandum 

Date: January 04, 2011 

From: Director, VA Heart of Texas Health Care Network (10N17) 

Subject: CAP Summary Report – Re-Evaluation of RME and EOC at 

the Central Texas Veterans Health Care System, Temple, 

Texas 

To: Director, Dallas Healthcare Inspections Division (54DA) 

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

1. I have reviewed the enclosed Healthcare Inspection Re-Evaluation of 

RME and EOC and have no additional suggestions for change. 

2. VISN 17 appreciates the opportunity to demonstrate the significant 

improvements Central Texas has implemented since the original OIG 

CAP visit in March 2010. 

(original signed by:) 

Lawrence Biro 
Re-Evaluation of RME and EOC at the Central Texas Veterans Health Care System, Temple, TX 

Appendix B 

Facility Director Comments 

VA Office of Inspector General 7 

Department of 

Veterans Affairs Memorandum 

Date: January 04, 2011 

From: Director, Central Texas Veterans Health Care System 

Subject: CAP Summary Report – Re-Evaluation of RME and EOC at 

the Central Texas Veterans Health Care System, Temple, 

Texas 

To: Director, VA Heart of Texas Health Care Network (10N17) 

1. I concur with the report. I see no changes or comments necessary. 

2. For additional information, you may contact me at 254-743-2306. 

 (original signed by:) 

Thomas C. Smith, III, FACHE 
Re-Evaluation of RME and EOC at the Central Texas Veterans Health Care System, Temple, TX 

Appendix C 

OIG Contact and Staff Acknowledgments 

OIG Contact Linda DeLong, Director 

Dallas Office of Healthcare Inspections 

Acknowledgments Cathleen King, Associate Director 

Gayle Karamanos 

Clarissa Reynolds 

Larry Ross 

Misti Kincaid, Program Support Assistant 

VA Office of Inspector General 8 
Re-Evaluation of RME and EOC at the Central Texas Veterans Health Care System, Temple, TX 

Appendix D 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VA Heart of Texas Health Care Network (10N17) 

Director, Central Texas Veterans Health Care System (674/00) 

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: John Cornyn, Kay Bailey Hutchison 

U.S. House of Representatives: John Carter, Bill Flores 

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

VA Office of Inspector General 9