Department of Veterans Affairs
 

Office of Inspector General
 

Healthcare Inspection
 

Electronic Waiting List Management
 

for Mental Health Clinics
 

Atlanta VA Medical Center
 

Atlanta, Georgia
 

Report No. 10-02986-215 July 12, 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)
 
Electronic Waiting List Management for Mental Health Clinics, Atlanta VA Medical Center, Atlanta, GA 

Executive Summary
 

The VA Office of Inspector General Office of Healthcare Inspections conducted an 

evaluation regarding inadequate management of the electronic waiting list (EWL) for 

several mental health (MH) clinics at the Atlanta VA Medical Center (facility) in Atlanta, 

GA. The confidential complainant alleged that as a result of excessive wait times, 

patients may be placed at risk. During the course of this review, we were also told of 

fiscal practices that negatively affected MH contract services. 

We substantiated that several MH clinics had significantly high numbers of patients on 

their EWLs over a period of months in fiscal year (FY) 2010, and we substantiated that 

facility managers were aware of the EWLs but were slow in taking actions to address the 

condition. We are unaware of any completed suicides; however, we did find evidence of 

MH EWL patients who attempted suicide, were hospitalized, or presented to the 

emergency department. We did not evaluate whether these events occurred as a direct 

result of being placed on MH EWLs, or whether they would have occurred in the course 

of regular, ongoing treatment. Nevertheless, large MH EWLs are inherently problematic 

as they represent impaired access to ongoing care. While the facility has since provided 

resources to eliminate the MH EWLs, ongoing actions will be needed to ensure the 

condition does not recur. 

We substantiated that FY 2010 funds were inappropriately used to pay a contractor’s 

FY 2009 expenses and that there were delays in payments to the contractor. We found 

that payment delays caused by defunding FY 2009 obligations in the Health Care for 

Homeless Veterans program had the potential to negatively impact contract providers, 

particularly the small Grant and Per Diem service providers. Although we identified 

one case where a Grant and Per Diem provider could not relocate patients to a more 

suitable environment until payments were received, we did not find evidence that other 

referrals or patient care were actually affected. 

We noted that the Veterans Health Administration’s performance measure on MH clinic 

access refers only to the first MH clinic evaluation; it does not measure ongoing access to 

MH services. As such, some Veterans Health Administration’s facilities may be fully 

compliant with the performance measure but may not be providing timely and ongoing 

treatment and services critical to this population’s MH maintenance and recovery. 

We recommended that the Medical Center Director ensure ongoing actions are taken to 

minimize and/or alleviate MH EWLs and that responsible staff follow fiscal guidelines. 

The Acting Veterans Integrated Service Network Director, who is also the Medical 

Center Director, agreed with the findings and recommendations and provided acceptable 

action plans. We will follow up on the planned actions until they are completed. 

VA Office of Inspector General i 
DEPARTMENT OF VETERANS AFFAIRS
 

Office of Inspector General
 

Washington, DC 20420
 

TO: Director, VA Southeast Network (10N7) 

SUBJECT: Healthcare Inspection – Electronic Waiting 

Mental Health Clinics, Atlanta VA Medical Cen

List 

ter, A

Management for 

tlanta, Georgia 

Purpose

The VA Office of Inspector General (OIG) Office of Healthcare Inspections conducted 

an evaluation regarding inadequate management of the electronic waiting list (EWL) for 

several mental health (MH) clinics at the Atlanta VA Medical Center (facility) in 

Atlanta, GA. The confidential complainant alleged that as a result of excessive wait 

times, patients may be placed at risk. During the course of this review, we were also told 

of fiscal practices that negatively affected MH contract services. The purpose of the 

review was to determine whether the allegations had merit. 

Background

The facility is a tertiary care facility located in Decatur, GA, that provides a broad range 

of inpatient and outpatient medical, surgical, geriatric, and MH services. Primary and 

MH care is also provided at community based outpatient clinics (CBOCs) in Smyrna, 

Lawrenceville, Oakwood Hall, East Point, Stockbridge, and Newnan, GA. The facility is 

part of Veterans Integrated Service Network (VISN) 7 and serves a veteran population of 

about 453,000 throughout 48 counties in GA. 

In fiscal year (FY) 2009, the facility served about 71,000 patients, a 7 percent increase 

over the previous year. In FY 2010, the facility served about 77,000 patients, an increase 

of 8 percent over the previous year. Between October 2009 and May 2010, the 

percentage of unique patients waiting greater than 30 days for appointments in the 

facility’s top 50 clinics rose from about 0.6 percent to about 4.5 percent. In addition to 

MH, we confirmed that several other clinics had EWLs, including those run by 

Ophthalmology, Hematology/Oncology, Physical Medicine and Rehabilitation, and Sleep 

Studies. Notably, patients were able to schedule timely primary care (PC) appointments 

during this time. 

VA Office of Inspector General 1 
Electronic Waiting List Management for Mental Health Clinics, Atlanta VA Medical Center, Atlanta, GA 

Mental Health Structure, Resources, and Workload 

The Mental Health Service Line (MHSL) offers general MH and specialized programs 

for post-traumatic stress disorder (PTSD), military sexual trauma, substance abuse 

treatment and recovery, homeless and residential care, and geropsychiatry. In FY 2010, 

the MHSL had about 305 full time equivalent employees (FTEE). There were 

39 vacancies at the end of the year, mostly in PC MH Integration,1 the Homeless 

Program, and the general MH clinic (GMHC). The budget was approximately $14M. 

A majority of patients receive their MH services through outpatient clinics and programs, 

either at the facility, in a CBOC, or at an offsite VA MH clinic location.2 The facility 

contracts with local community service boards (CSBs) when demand for services exceeds 

MH resources. CSBs typically provide outpatient MH, developmental disability, and 

addiction services to residents of their defined counties. VISN 7 contracts with almost 

20 different CSBs across Georgia to provide general outpatient MH services, crisis 

stabilization, and psychosocial rehabilitation/day treatment to patients referred by any of 

its 8 VA medical centers. 

The facility’s inpatient MH unit has undergone renovation over the past year and 

currently has 40 acute MH beds. The facility contracts with a local private-sector 

psychiatric facility (referred to as the “IP contractor” in the remainder of this report) for 

patients requiring hospitalization that cannot be accommodated on the facility’s MH unit 

due to lack of available beds. 

MH workload has increased 17 percent since 2008. Table 1 below shows both the 

facility and contractor workload variances for FY 2009–FY 2010. Inpatient workload is 

defined as the number of discharges from an inpatient setting. Outpatient workload 

reflects the number of patient encounters with MH providers. 

Table 1. MH Workload FY 2009–FY 2010 

FY 2009 FY 2010 Increase (Decrease) 

Inpatient (VA) 651 993 52.53 % 

Inpatient (IP contractor) 899 625 (43.8 %) 

Outpatient (VA) 201,915 225,017 11.44 % 

Outpatient (contractors) 796 657 (17.46 %) 

1 PC MH Integration consists of psychologists, assigned to work in Primary Care clinics, who assess and treat
 

patients with routine MH needs, thus minimizing the referrals to specialty MH clinics.

2 Due to space constraints, some VA-staffed clinics occupy leased space in the community.
 

VA Office of Inspector General 2 
Electronic Waiting List Management for Mental Health Clinics, Atlanta VA Medical Center, Atlanta, GA 

In addition to the number of new patients enrolling in VA care, facility and MHSL 

managers attributed the higher volume of patients seeking MH services to: 

	 Required follow up to positive MH-related screening questions completed by PC 

providers. For example, a comparison of positive depression screens (for the 

period October to April) that prompted referral to the GMHC rose from 3,848 in 

FY 2009 to 11,367 in FY 2010. 

	 An increase in the number of PC providers as new CBOCs opened. While 

professional MH staffing was approved for the CBOCs, difficulty in recruiting for 

some positions delayed the hiring process. CBOC patients requiring MH services 

were referred to the facility’s GMHC. 

	 The addition of a “psychosocial stressors”3 question to the mandated suicide 

assessment. The facility found, via its aggregate root cause analyses (RCA) 

process, that psychosocial stressors were an indicator of suicidal behavior. 

Adding this question to the screen; however, increased the number of positive 

responses prompting referrals to the GMHC. 

EWL Guidance and Requirements 

The EWL is the official Veterans Health Administration (VHA) wait list. VHA 

Directive 2009-070, VHA Outpatient Scheduling Processes and Procedures, 

December 17, 2009, states, “The EWL is used to list patients waiting to be scheduled, or 

waiting for a panel assignment. In general, the EWL is used to keep track of patients 

with whom the clinic does not have an established relationship (e.g. [for example], the 

patient has not been seen before in the clinic).” VHA Handbook 1160.01, Uniform 

Mental Health Services in VA Medical Centers and Clinics, dated September 11, 2008, 

states that all new patients requesting or referred for MH services “must receive an initial 

evaluation within 24 hours, and a more comprehensive diagnostic and treatment planning 

evaluation within 14 days.” For measuring wait times, VHA defines a “new” patient as 

any patient not seen by a qualifying provider in a specific clinic within the previous 

24 months. For example, an “established” PC patient referred to the MH clinic would be 

classified as a new patient. 

In January 2010, a confidential complainant reported to the OIG that facility managers 

were not adequately addressing EWLs in the MH clinics. The complainant specifically 

alleged that: 

	 A high number of patients were on various MH clinic EWLs, which may place 

some patients at risk for negative events or outcomes. 

	 Despite VISN and facility management being aware of the risk to patients, no 

actions had been taken to resolve the issue. 

3 Psychosocial stressors include conditions such as unemployment, homelessness, or marital discord. 

VA Office of Inspector General 3 
Electronic Waiting List Management for Mental Health Clinics, Atlanta VA Medical Center, Atlanta, GA 

On January 28, we contacted a facility manager requesting information about the EWLs. 

Management confirmed that there were EWLs in several clinics across the facility and 

advised that the VISN was providing $2M to address them (the funding was received the 

same day). Based on this information, we deferred investigation of these complaints 

because the facility and VISN were taking action to resolve the condition. 

On May 7, we contacted facility management to determine the status of the MH EWLs 

and learned that the number of patients awaiting appointments in the GMHC and 

substance use disorder (SUD) clinics had increased since January. We further learned 

that the MHSL was offered $250K from the original $2M allotment but was unable to use 

any of the funding due to contract negotiation issues. 

During the course of this review, we also received complaints regarding MH-related 

fiscal matters: 

	 FY 2010 funds were inappropriately used to pay for FY 2009 expenses. 

	 IP contractor payments were delayed. 

	 De-funding of obligated appropriations and delays in contractor payments 

negatively affected MH contract service providers. 

We were told that some managers had negative personal feelings about the MHSL and 

MH services. However, we did not evaluate these assertions as they are perceptions that 

cannot be objectively confirmed or refuted. 

Scope and Methodology

We conducted site visits over several weeks between June 3 and August 3, 2010. Prior to 

our visits, we reviewed VHA Directive 2009-070 and VHA Handbook 1160.1. We 

interviewed the facility Director, Chief of Staff (COS), Chief Financial Officer (CFO), 

MHSL Chief, MHSL Administrative Officer (who is also the Contracting Officer’s 

Technical Representative [COTR] for the IP contract), the two MHSL physicians with 

program responsibility for the GMHC and SUD clinic, the VISN 7 CFO, Chief of Fee 

Basis Services, and other facility staff knowledgeable about the issues. We also 

interviewed the local CSB Executive Director and Clinical Coordinator and the IP 

contractor’s Director of Business Operations. We reviewed the MHSL’s waiting list 

from September 2009 to November 2010; quality management, workload, and 

productivity reports; budgeting and vendor payment documents; email correspondence; 

CSB contracts; and individual patients’ medical records. 

This review was performed in accordance with Quality Standards for Inspection and 

Evaluation published by the Council of the Inspectors General on Integrity and 

Efficiency. 

VA Office of Inspector General 4 
Electronic Waiting List Management for Mental Health Clinics, Atlanta VA Medical Center, Atlanta, GA 

Inspection Results

Summary of Events 

Several factors contributed to the facility’s inability to meet the growing demand for MH 

services, including (1) the need to contract for inpatient hospitalization and its result on 

the MHSL budget, and (2) the lack of MH clinic capacity to manage outpatients. 

Need for IP Contract. Since 2008, the facility has experienced a 17 percent increase in 

demand for MH services and an increase in the number of patients in crisis who required 

hospitalization. While the IP contract has been used for “overflow” MH patients for 

many years, the volume of referrals increased in 2008–2009 when the facility was 

undergoing renovations to increase the number of acute MH beds within the facility from 

30 to 40 beds. In FY 2009, the facility paid the IP contractor approximately $6.7M for 

acute hospitalization and other services.4 In July 2009, the MHSL requested and was 

approved for approximately $4.3M to fund the IP contract in FY 2010. The bed 

renovation project was initially scheduled for completion on October 1, 2009, so the 

budget projection of $4.3M presumed a decreased need for IP contractor beds due to the 

increased availability of facility acute MH beds. However, construction and plumbing 

problems delayed the project and completion dates were continuously revised. Beds 

were added in January and April, but FTEE to staff the new beds was not fully in place 

until July 2010. 

MH Clinic Capacity. Due to space and resource limitations, the MHSL was unable to 

hire new FTEE to staff the on-site GMHC. During the July 2009 budget call, the MHSL 

requested approximately $6.8M for outpatient contract services for FY 2010. On 

October 14, $5M was approved. However, on November 12, the allotment was reduced 

to $1M. As a result, the MHSL stopped making referrals to the CSBs and actively tried 

to bring CSB patients back into the facility for services. 

Facility staff did not make any referrals to the local CSB, which provides services to 

residents of the county where the facility is located and many of its patients reside, from 

November 2009 to May 2010 due to the lack of contract funds. The GMHC EWL began 

to increase in October 2009. 

Facility Interim Actions 

As the EWLs grew, the MHSL used the MH Assessment Team (MHAT) to assess 

patients referred for MH services who could not be scheduled in the desired MH clinic 

within 14 days due to lack of clinic capacity. The MHAT consisted of three psychiatrists 

4 Electroconvulsive shock therapy (ECT) was also discontinued at the facility during this time, requiring contracted 

care for that service as well. 

VA Office of Inspector General 5 
Electronic Waiting List Management for Mental Health Clinics, Atlanta VA Medical Center, Atlanta, GA 

who assessed the referred patients, and based on their clinical determination of risk, 

would either admit the patient to an acute MH unit (facility or IP contractor) or develop 

an outpatient treatment plan that could include medication, referral for other facility or 

community-based services, and/or placement on the desired program’s EWL. 

The MHSL was offered $250K in late March 2010. We received conflicting testimony 

on how the funds were to be used (contract care versus FTEE); however, interviewees 

generally agreed that the intent of the additional resources was to directly or indirectly 

address the EWL. 

We were told that negotiations between the MHSL and local CSB staff were 

unsuccessful, reportedly due to the CSB’s concerns about the timeliness of past payments 

and the structure of approved services (which included one initial assessment and 

two medication reconciliation appointments). Because the MHSL could not spend the 

$250K quickly, facility managers reallocated the funds to other services. 

In mid-May, the MHSL was told they would be receiving $2.3M and to proceed with 

negotiations with the local CSB. The additional funding permitted a restructuring of 

contracted services to include one initial assessment and six follow-up visits. The facility 

resumed referrals to CSBs on May 29, and the MHSL officially received the $2.3M on 

June 2. 

Managers were also taking actions to hire additional FTEE. In an effort to reduce the 

number of referrals to the GMHC, “integration psychologists” were added to the PC 

teams to address MH issues within the CBOCs. As of February 2, 2011, the facility had 

hired 11 integration psychologists. In addition, most CBOCs5 were staffed with some 

combination of a psychiatrist, psychologist, and/or social worker to manage MH needs 

within that setting, when appropriate. 

Issue 1: EWL and Patient Safety Concerns

We substantiated the allegation that a “high” number of patients were on various MH 

clinic EWLs during the timeframe referenced by the complainant. While several MH 

clinics had EWLs (mostly of 50 patients or less), we found the SUD and GMHC clinics 

to be most concerning as: (1) their EWLs exceeded 100 patients; (2) they were more 

likely to serve patients not already being followed by another MH provider; and/or (3) the 

patients waiting for appointments in these clinics were more likely to be considered at 

risk due to diagnosis or lack of an established MH provider. 

5 One CBOC does not have a MH team onsite yet. 

VA Office of Inspector General 6 
Electronic Waiting List Management for Mental Health Clinics, Atlanta VA Medical Center, Atlanta, GA 

Table 2. Substance Use Disorder and General Mental Health Clinic EWLs (FY 2010) 

0 

100 

200 

300 

400 

500 

600 

SUD 

GMHC 

The SUD EWL exceeded 100 patients from October 1, 2009, through 

June 1, 2010, and some of those patients were on the EWL for the entire 8-month period. 

Over the past several years, MHSL leaders had attempted to evaluate the access and 

timeliness issues in the SUD program and had implemented actions to improve these 

conditions. However, according to the SUD clinic’s leadership, demand for services 

continued to increase, resulting in an EWL for “initial assessment” for SUD treatment. A 

System Redesign team evaluated the SUD program, and in its February 2010 report, 

made several recommendations to improve program efficiency and patient flow. As 

processes were restructured, the EWL began to improve. In July, the SUD EWL dropped 

to 41, and by October, it was down to 3 patients. 

MHSL managers reported, and fiscal data confirmed, that the GMHC EWL began to 

increase when resources were no longer available to fund CSB referrals. The GMHC 

EWL quintupled, from 94 patients on October 1, 2009, to 551 patients on May 1, 2010. 

Some of those patients had been on the EWL for the entire 8-month period. During this 

time, facility clinicians did not refer any patients to the local CSB. In mid-May, after the 

MHSL was informed additional funding was forthcoming, referrals to the CSB resumed. 

On June 1, the GMHC EWL was 359, and by October 1, it was down to 11 patients. 

The following data supports concerns that some of the EWL patients may have been at 

risk for negative outcomes or events before they could be seen by the MH clinic for 

which they were awaiting an appointment: 

	 From October 1, 2009, to March 31, 2010, there were 419 patient admissions to 

contract facilities for MH reasons; 38 (9 percent) of those admissions involved 

patients on a MH EWL. During the same period, 44 patients on a MH EWL were 

admitted to the facility’s acute MH unit. This data implies that the patients’ 

clinical conditions deteriorated while they were on EWLs. 

VA Office of Inspector General 7 
Electronic Waiting List Management for Mental Health Clinics, Atlanta VA Medical Center, Atlanta, GA 

	 From July 1, 2009, through March 31, 2010, there were 211 facility patients who 

either self-reported or were observed to display suicidal behavior. Of those, 

148 (70 percent) were categorized as “attempters” and 63 were categorized as 

patients with serious suicidal ideation. Of the 211 patients, 24 (11 percent) were 

on one of the MH EWLs at the time of the event, and 16 (67 percent) of the 

24 patients actually attempted suicide. There were no completed suicides of 

patients on the MH EWLs. 

While the conditions noted above appear serious, we could not say with certainty that 

those events would have been prevented had the patients been scheduled promptly into 

the appropriate MH clinics. Our medical review of MH EWL patients reflected that the 

MHAT was assessing patients and developing interim treatment plans pending the 

scheduling of an appointment in the desired MH clinic. 

We reviewed the medical records of 67 patients assessed by the MHAT and placed on a 

MH EWL during February 2010.6 Our sample included 30 randomized patients and 

37 patients with specific diagnoses, such as PTSD or psychosis, which would typically 

warrant closer follow-up. Our medical record review focused on the following questions: 

	 While on a specified MH EWL, were patients seen or followed by another MH 

clinic or provider? 

	 If not followed by MH, were the MH EWL patients being followed by the PC 

provider? 

	 Did any of the MH EWL patients have any unusual events or needs while on the 

EWL? We included suicidal gestures and related contacts, and hospital 

admissions and emergency department (ED) visits related to a MH condition. 

Table 3. Medical Record Review Results 

Seen by 

MH 

Seen by 

PC 

Patients Experiencing Events or Special Needs 

Randomized 

records (N=30)* 

26 3 5  3 Suicide Prevention Hotline (SPH) calls 

 2 ED visits related to MH condition 

Diagnosis-specific 

records (N=37) 

36 1 8  3 high risk suicide flags placed/continued 

 1 SPH call 

 2 admissions for MH-related reasons 

 2 high-risk cases prompting safety actions 

* One patient did not show for a follow-up appointment and efforts to reach him were unsuccessful. 

6 GMHC=26; SUD=18; Trauma Recovery=9; Compensated Work Therapy=7; HCHV=4; and Substance Abuse 

Trauma Recovery=3 

VA Office of Inspector General 8 
Electronic Waiting List Management for Mental Health Clinics, Atlanta VA Medical Center, Atlanta, GA 

We found that even though these patients were on a MH EWL, they were still receiving 

some level of service or follow-up through another MH provider or through PC. For 

example, a patient could have been followed by clinicians in the Homeless Program 

while also on the SUD EWL. Eleven (16 percent) of the 67 patients were started on 

psychiatric medications while on a MH EWL, and documentation reflected that 

reasonable monitoring occurred. We noted that ED visits were typically for medication 

refills and non-emergent MH issues. MHAT assessments were completed, and interim 

treatment plans reflected that MH EWL patients were offered information and support 

through facility and non-VA resources while awaiting more specialized facility MH 

treatment modalities. PC progress notes also contained evidence that providers were 

generally aware of their patients’ MH conditions and EWL status. 

We are unaware of any completed suicides among the 67 patient medical records we 

reviewed; however, we did find evidence of MH EWL patients who attempted suicide, 

were hospitalized, or presented to the ED. We did not evaluate whether these particular 

events occurred as a direct result of being placed on MH EWLs, or whether they would 

have occurred in the course of regular, ongoing treatment. Large MH EWLs are 

inherently problematic as they represent impaired access to ongoing care. 

As of October 2010, the GMHC and SUD EWLs had largely been resolved. However, 

leadership needs to assure ongoing actions are taken to minimize and/or alleviate MH 

EWLs. 

Issue 2: Responsiveness of Facility Leaders

We confirmed that VISN and facility managers were aware of the increasing MH EWLs 

and the potential vulnerability of patients as early as November 25, 2009, when the 

MHSL briefed the VISN and facility managers on the “clinical urgency to address the 

EWLs” and sought funding for contracts and to staff vacancies. Over the next 

several months, managers were alerted to the ongoing EWL concerns, but it appeared that 

they were slow to take action: 

1. A January 7, 2010, VISN team report about MH services identified a priority 

challenge as “preventing patients needing MH services from waiting a significant 

time to receive them.” The VISN team recommended reallocating resources in the 

outpatient programs, including hiring a three-person team to manage patients 

awaiting MH care. This three-person team was not approved until June 2010.7 

2. On January 28, facility management said that the VISN was providing $2M in 

funding to address EWLs in several outpatient clinics. The funding was received 

on station the same day; however, funding was not offered to the MHSL until 

late March. 

7 Because of space limitations, the team could not be co-located. This condition has resulted in fewer patients being 

seen than originally projected. 

VA Office of Inspector General 9 
Electronic Waiting List Management for Mental Health Clinics, Atlanta VA Medical Center, Atlanta, GA 

3. An	 aggregate RCA on suicide behaviors signed by facility managers on 

February 4 reflected a root cause/contributing factor as “EWLs creating a 

vulnerable period when those patients do not have access to adequate MH care.” 

Facility leaders later told us that the decision on how to allocate the initial $2M was 

based on clinical Service chiefs presenting their “cases” to the COS. The COS told us 

that he believed the MHAT was appropriately triaging patients and that patients on the 

MH EWLs were safe. The COS reported that he prioritized based on clinical need and 

available resources. In late March, facility managers sent an e-mail offering the MHSL 

$250K to reduce EWLs; however, the funds were returned as the CSB contract was still 

being negotiated. 

In June, the VISN provided another $5M to address EWLs across the facility’s outpatient 

clinics; the MHSL received $2.3M. With this infusion of funding, referrals to the CSB 

recommenced. This action, coupled with the addition of new MH staff and primary care 

integration psychologists, resulted in the GMHC EWL largely being eliminated. Again, 

leadership needs to assure ongoing actions are taken to minimize MH EWLs in the 

future. 

Issue 3: Payment of FY 2009 Expenses with FY 2010 Funds

We substantiated the allegation that FY 2010 funds were inappropriately used to pay for 

FY 2009 expenses. This condition occurred because there were insufficient obligations 

recorded at the end of FY 2009. The facility paid approximately $589,000 for FY 2009 

MH inpatient expenses with FY 2010 annual appropriations, contrary to VA guidance. 

The procedures for recording obligations for outside hospitalization costs is covered 

under VA Controller Policy, MP4, Part V, Chapter 3; 3A.07. 

VA Financial Policies and Procedures, Volume II, Chapter I, page 4, states that VA’s 

policies for the administrative control of funds must: 

Prescribe a system for positive administrative control of funds designed to 

ensure that obligations and expenditures in each appropriation account or 

fund do not exceed the amount available, are made for the period for which 

funds are available, and are used for proper purposes.... 

Appropriations are categorized as annual, multi-year, or no-year. No-year appropriations 

allow the facility to obligate funds for an indefinite period of time. Appropriated funds 

are legally available to be obligated subject to the following criteria: 

	 Obligation or expenditure must be authorized. 

	 Obligation must occur within the time limits applicable to the appropriation. 

	 Obligation and expenditure must be within the amounts established by Congress. 

VA Office of Inspector General 10 
Electronic Waiting List Management for Mental Health Clinics, Atlanta VA Medical Center, Atlanta, GA 

The facility has a no-year appropriations account for MH services. No-year 

appropriations may be funded with additional appropriations, if available, so that 

obligations can be matched to the proper year’s appropriations. 

In September 2009, Fiscal Service managers redirected unobligated MH appropriations to 

other appropriations accounts as a part of the year-end budgetary process. During the 

period September 15–November 22, 2009, managers stopped payments to the IP 

contractor because of year-end closing procedures. Meanwhile, outstanding bills were 

left unpaid and additional bills accumulated because of continued patient referrals to the 

IP contractor. Facility officials were unable to pay all of the FY 2009 bills because there 

were insufficient funds available from FY 2009 appropriations. On November 23, 2009, 

the facility began payment of FY 2009 bills to the IP contractor. 

We reviewed FY 2010 IP contractor payment histories for inpatient stays in association 

with vendor history data from VSSC. Our analysis resulted in identifying approximately 

$589,000 in expenses incurred prior to September 30, 2009, which were paid under the 

FY 2010 Obligation Code OC1001. 

Several internal facility emails verified this condition: 

	 On November 19, 2009, a facility budget analyst reported that an additional 

$500,000 would be required to pay for FY 2009 invoices. Later that morning, a 

supervisory budget analyst confirmed that these FY 2009 invoices would be paid 

with FY 2010 funds. 

	 On March 3, 2010, the Assistant Chief, Purchase Care Fee Basis, confirmed with 

the COTR that an FY 2010 obligation code (OC1001) would be used to pay for 

FY 2009 invoices. 

	 Also on March 3, the Chief of Fee Basis Services confirmed that FY 2010 funds 

were used because there were no more FY 2009 MH funds available. 

Fiscal Service managers’ actions and the series of emails confirmed the intent to use 

FY 2010 funds to pay FY 2009 bills. In April 2010, the CFO requested additional 

FY 2009 funds to pay additional claims presented by the IP contractor. 

Issue 4: Delays in Payments to the IP Contractor

We determined there were significant delays in FY 2010 payments to the IP contractor 

for inpatient stay billings from FY 2009 to FY 2010. The IP contract included a 

provision about the Prompt Payment Act, which requires agencies to pay commercial 

obligations within certain time periods and to pay interest penalties when payments are 

late. Review of the IP contractor’s FY 2010 payment history through September 2010 

revealed that the facility paid interest totaling $5,048 on 249 out of 838 inpatient stay 

invoices totaling $6.365M. Causes for the delays included Fiscal Service’s moratorium 

VA Office of Inspector General 11 
Electronic Waiting List Management for Mental Health Clinics, Atlanta VA Medical Center, Atlanta, GA 

on payments from mid-September through late-November 2009 and difficulties 

reconciling outstanding payments owed between the IP contractor and the facility. 

We reviewed emails between the IP contractor and the facility for the period 

October 2009–March 2010. A sample of these emails discussed the facility’s hold placed 

on payment of funds, delays in payment of outstanding claims, and increased levels of 

concern by the contractor over non-payment. 

	 On October 14, 2009, the Chief of Fee Basis informed the COTR that the 

accounting department had not allowed them to release any payments since before 

September 18, 2009, and there was no official release date in the future. 

	 On March 19, 2010, a budget analyst informed the Chief of Fee Basis that there 

was $825,000 in outstanding pending IP contractor claims with dates of service in 

FY 2009. 

	 On November 16, 2009, the IP contractor’s CFO requested definitive updates from 

the Chief of Fee Basis because of communication problems with facility personnel 

regarding the status of unpaid invoices in excess of $1.0M. In prior 

communications, the CFO emphasized that senior corporate personnel had 

concerns over non-payment of outstanding invoices. 

We found no evidence that the IP contractor refused to accept VA contract patients 

during the non-payment period. However, the substantial amount owed, accumulating 

over several months, may have negatively affected the VA-IP contractor referral 

relationship and reduced the availability of this emergent service. 

Issue 5: Defunding of Obligated Appropriations

We substantiated the allegation that defunding of obligated appropriations and delays in 

contractor payments could have negatively affected contract service providers, 

specifically, the Health Care for Homeless Veterans (HCHV) Grant and Per Diem 

(G&PD) program. 

Fiscal Service managers de-funded amounts obligated for the G&PD program in 

September 2009, resulting in delayed payments to contractors. Due to these delays, a 

contractor was unable to relocate veterans from unsuitable housing in a timely manner. 

Internal facility emails confirmed that previously appropriated and obligated funds were 

de-funded. 

On October 14, 2009, the HCHV Director summarized the funding issues for the 

Associate Director facility in a chain of emails dating back to August 14, 2009. 

	 On September 9, 2009, the HCHV Director informed a budget analyst that there 

was approximately $322,000 in pending G&PD bills for FY 2009 with 

$134,000 in invoices received. 

VA Office of Inspector General 12 
Electronic Waiting List Management for Mental Health Clinics, Atlanta VA Medical Center, Atlanta, GA 

	 On September 10, a budget analyst requested that the HCHV Director decrease 

obligations of funds to allow for payment of $134,000 of invoices and a 

$5,000 cushion. 

	 On September 11, the HCHV Director decreased obligations at the request of the 

budget analyst by approximately $246,000. This resulted in $246,000 of 

unobligated funds directed to other appropriations accounts, which left no funds 

available for pending bills. 

Other emails confirmed that these funding issues still existed nearly a month later. On 

October 8, the COTR informed Fiscal Service that the MHSL had many FY 2009 

invoices that were being rejected for payment because funds were de-obligated. On 

October 9, the HCHV Director informed the MHSL Chief and COTR that there was still 

approximately $320,000 in unpaid FY 2009 invoices. Additionally, the HCHV Director 

reported that a contractor who supplied community housing for homeless veterans was 

unable to relocate veterans from sub-standard housing due to lack of payment. 

Issue 6: Incidental Concern – Adequacy of Performance Measure

In October 2010, VHA implemented a new performance measure relative to wait times 

for new MH patients. This measure tracks the percent of new patients waiting to be seen 

within 14 days of their desired appointment date. The intent of the new performance 

measure was to ensure that patients were promptly seen by a MH professional to evaluate 

clinical risk and initiate intervention for patients with acute MH needs. Thus, the 

performance measure calculates the timeliness of access to a qualified MH provider for a 

single evaluation and treatment plan. However, VHA currently does not have a measure 

tracking whether there is consistent and ongoing access to care, such as time to 

second appointment. Because of this limitation, the facility was able to achieve 

100 percent compliance with the access measure for the first three quarters of FY 2010 in 

spite of having hundreds of patients on various MH EWLs. 

We suggest that VHA consider this issue when developing future MH-related 

performance measures. 

Conclusions

We substantiated that several MH clinics had significantly high numbers of patients on 

their EWLs over a period of months in FY 2010, and we substantiated that facility 

managers were aware of the EWLs but were slow in taking actions to address the 

condition. We are unaware of any completed suicides; however, we did find evidence of 

MH EWL patients who attempted suicide, were hospitalized, or presented to the ED. We 

did not evaluate whether these events occurred as a direct result of being placed on MH 

EWLs or whether they would have occurred in the course of regular, ongoing treatment. 

However, large MH EWLs are inherently problematic as they represent impaired access 

VA Office of Inspector General 13 
Electronic Waiting List Management for Mental Health Clinics, Atlanta VA Medical Center, Atlanta, GA 

to ongoing care. While the facility has since provided resources to eliminate the MH 

EWLs, ongoing actions will be needed to ensure the condition does not recur. 

We substantiated that FY 2010 funds were inappropriately used to pay FY 2009 IP 

contractor expenses and that there were delays in the timely payment of the IP 

contractor’s invoices. Defunded FY 2009 HCHV obligated appropriations resulted in 

payment delays that had the potential to negatively impact contract providers, particularly 

the small homeless GPD service providers. Although we identified one case where a 

GPD provider could not relocate patients to a more suitable environment until payments 

were received, we did not find evidence that other referrals or patient care were actually 

affected. 

We noted that VHA’s performance measure on MH clinic access refers only to the 

first MH clinic evaluation; it does not measure ongoing access to MH services. As such, 

some VHA facilities may be fully compliant with the performance measure, but may not 

be providing timely and ongoing treatment and services critical to this population’s MH 

maintenance and recovery. 

Recommendations

Recommendation 1. We recommended that the VISN Director, in conjunction with the 

Medical Center Director, ensure ongoing actions are taken to minimize and/or alleviate 

MH EWLs. 

Recommendation 2. We recommended that the VISN Director, in conjunction with the 

Medical Center Director, require that Fiscal Service monitors and enforces the provision 

to match expenditures with the proper year’s appropriations as outlined in VA Financial 

Policies and Procedures. Obligations should be recorded in accordance with the guidance 

in the VA Controller Policy. The CFO should follow administrative procedures to ensure 

that FY 2009 expenditures are reported in the appropriate fiscal year. 

Recommendation 3. We recommended that the VISN Director, in conjunction with the 

Medical Center Director, require the Chief of Fee Basis to establish procedures to ensure 

that all invoices received by the facility are appropriately tracked, including date of 

receipt, and that invoices are reconciled with vendor records and paid in a timely manner. 

Recommendation 4. We recommended that the VISN Director, in conjunction with the 

Medical Center Director, require that Fiscal Service ensure that properly obligated 

HCHV funds are not defunded. 

VA Office of Inspector General 14 
Electronic Waiting List Management for Mental Health Clinics, Atlanta VA Medical Center, Atlanta, GA 

Comments

The Acting VISN Director, who is also the Medical Center Director, agreed with the 

findings and recommendations and provided acceptable action plans (see Appendixes 

A and B, pages 16–21 for the full text of their comments). The Medical Center Director 

has implemented processes to ensure that ongoing needs of all clinical services are 

discussed with appropriate service line managers and resolutions/actions implemented to 

minimize and/or alleviate MH EWLs and all other EWLs. Fiscal Services has monitors 

to match expenditures with prior year’s appropriations, and the Fee Chief will ensure 

invoices are tracked and documented upon receipt and certification by the COTR. 

Purchased Care will process payments authorized by the COTR within 20 days of receipt, 

and the cover sheet will be annotated accordingly. Financial Management has 

implemented a Specific Purpose funding tracking system to ensure all special program 

funds are monitored for appropriate funding and timely obligations. 

We will follow up until the planned actions are completed. 

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

Assistant Inspector General for
 

Healthcare Inspections
 

VA Office of Inspector General 15 
Electronic Waiting List Management for Mental Health Clinics, Atlanta VA Medical Center, Atlanta, GA 

Appendix A

VISN Director Comments
 

Department of

Veterans Affairs Memorandum

Date: June 15, 2011 

From: Acting Director, VA Southeast Network, (10N7) 

Subject: Healthcare Inspection – Electronic Waiting List Management 

for Mental Health Clinics, Atlanta VA Medical Center, Atlanta, 

Georgia 

To: Director, Atlanta Office of Healthcare Inspections (54AT) 

Thru:	 Director, VHA Management Review Service (10A4A4) 

I concur with the findings and recommendations of this 

report. We will manage the Electronic Waiting list (EWL) 

per VHA guidance and based on facility/VISN resources. 

(original signed by:) 

James A. Clark, MPA
 

Acting Director, VA Southeast Network (10N7))
 

VA Office of Inspector General 16 
Electronic Waiting List Management for Mental Health Clinics, Atlanta VA Medical Center, Atlanta, GA 

Appendix B

Facility Director Comments
 

Department of

Veterans Affairs Memorandum

Date:	 June 15, 2011 

From:	 Director, Atlanta VA Medical Center (508/00) 

Subject:	 Healthcare Inspection – Electronic Waiting List Management 

for Mental Health Clinics, Atlanta VA Medical Center, Atlanta, 

Georgia 

To:	 Acting Director, VA Southeast Network (10N7) 

1. We appreciate the OIG’s review to ensure that MH EWL receives 

the attention needed from senior management as well as other EWL issues 

for the Medical Center. We would like to reiterate that the healthcare 

inspection did not present evidence that significant negative outcomes 

occurred as a direct result of being on the MH EWL. In addition, the report 

confirmed that although the patients were on a MH EWL, they were still 

receiving some level of service or follow-up through another MH provider 

or through PC. However, we agree that EWLs represent a barrier to care 

and should be minimized. Management closely monitors all patients on the 

EWL to ensure timely treatment/care occur based on medical necessity. 

2. Although additional funds were received from the VISN to remedy 

temporarily the EWL, the amount received did not adequately match our 

increase in patients served from 2009 to 2010. The Medical Center 

experienced 7 and 8 percent growth respectively from 2009 to 2010. We 

project another 7–8 percent growth for fiscal year 2012. 

4. The Medical Center prioritizes the needs of our veterans to ensure 

that they receive care based on medical necessity and priority scheduling. 

With regard to unit cost per patient, the Medical Center is ranked 9th 

among other VA facilities, 1st in VISN 7, and 1st with all other 1A facilities 

(Unit Cost Report 1-Fiscal Year 2011Q1). In addition, the Medical Center 

is -13.57 percent below the National mean for cost efficiency (Unit Cost 

Report 1-Fiscal Year 2011Q1). We will continue to utilize our finite 

resources to ensure quality care is delivered, second to none, and that 

VA Office of Inspector General 17 
Electronic Waiting List Management for Mental Health Clinics, Atlanta VA Medical Center, Atlanta, GA 

management continues to address systems improvements through 

operational efficiencies. 

5. One of the causes of delays in payment to the vendor was untimely 

receipt of completed invoices. VHA staff picked up the invoices January 

29, 2010, from the vendor to assist with timely reconciliation. Some of the 

invoices included several dates of services for fiscal year 2009. Additional 

time was needed to process and reconcile these invoices. 

The Medical Center will continue to provide ongoing support for all EWLs. 

Priorities are based on input from our clinical Service Line Mangers and 

discussed with our Chief of Staff. 

We concur with the recommendations and have provided our response and 

action plans. 

(original signed by:) 

James A. Clark, MPA 

Director, Atlanta VA Medical Center (508/00) 

VA Office of Inspector General 18 
Electronic Waiting List Management for Mental Health Clinics, Atlanta VA Medical Center, Atlanta, GA 

Director’s 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’s report: 

OIG Recommendation 

Recommendation 1. We recommended that the VISN Director, in 

conjunction with the Medical Center Director, ensure ongoing actions are 

taken to minimize and/or alleviate MH EWLs. 

Concur Target Completion Date: Completed 

Facility’s Response: 

EWL support/resources are provided to all areas of our clinical services, 

and clinical judgment of the Chief of Staff is supported by input from his 

Service Line Managers. We will work to minimize/eliminate all EWL 

entries prioritized by medical need and within available resources and 

request additional support from the VISN/VACO if necessary. 

The Atlanta leadership has implemented processes to ensure that ongoing 

needs of all clinical services are discussed with appropriate service line 

managers, and resolutions/actions implemented to minimize and/or 

alleviate MH EWLs and all other EWLs. This includes weekly discussions 

with the Medical Center Pentad, Financial Manager, Administrative 

Officers, Chief of Health Administration Services, Administrative Assistant 

to Chief of Staff, and other senior leaders as appropriate to review service 

line input on EWLs and prioritization of needed resources. Resources are 

approved based on clinical priorities. 

The Medical Center will continue best use of its finite resources to ensure 

care and services are provided timely, implement management efficiencies 

in areas needing systems improvements, and support our clinical services to 

address all EWLs adequately. 

Recommendation 2. We recommended that the VISN Director, in 

conjunction with the Medical Center Director, require that Fiscal 

Service monitors and enforces the provision to match expenditures with the 

proper year’s appropriations as outlined in VA Financial Policies and 

Procedures. Obligations should be recorded in accordance with the 

VA Office of Inspector General 19 
Electronic Waiting List Management for Mental Health Clinics, Atlanta VA Medical Center, Atlanta, GA 

guidance in the VA Controller Policy. The CFO should follow 

administrative procedures to ensure that FY 2009 expenditures are reported 

in the appropriate fiscal year. 

Concur Target Completion Date: Completed 

Facility’s Response: 

Fiscal Services have monitors and enforces the provision to match 

expenditures with prior year’s appropriations as outlined in VA Financial 

Policies and Procedures. In FY2009, an interim solution was necessary to 

pay mental health vendor for services provided without funding because 

our contractual obligations exceeded appropriated funds. The Atlanta 

VAMC [VA Medical Center] experienced a very high volume of veterans 

requiring mental health services, especially inpatient mental health 

admissions to our contracted vendor due to our internal bed capacity 

limitations. The leadership at the Atlanta VAMC met frequently to ensure 

patient care was provided to our mental health patients timely. In addition, 

approximately $850,000 of additional institutional claims was submitted by 

the vendor during January 2010. 

The CFO consulted our VISN CFO regarding the need to utilize 

FY10 funds to pay for prior year’s expenditures until the FY09 funds 

became available. 

Prior year funds were requested and identified for the Atlanta VAMC 

during April 2010. At that time, transfers were processed to reflect 

expenditures appropriately to the FY09 appropriation. This interim 

solution was necessary to prevent disruption in services to not only our 

mental health high-risk patients but also all other veterans served by the 

Atlanta VAMC. 

Financial Management and Health Administration has implemented steps to 

ensure Mental Health Managers stay within their allocated budget or takes 

appropriate actions to request additional funds prior to authorization of 

services. Steps include monthly face-to-face meetings with Mental Health 

Managers, monthly Financial Update and Projection reports, developed 

estimating and tracking tool for Service Line’s use, and weekly Non-VA 

Purchase Care projection reported to Medical Center Leadership. 

Recommendation 3. We recommended that the VISN Director, in 

conjunction with the Medical Center Director, require the Chief of Fee 

Basis to establish procedures to ensure that all invoices received by the 

VA Office of Inspector General 20 
Electronic Waiting List Management for Mental Health Clinics, Atlanta VA Medical Center, Atlanta, GA 

facility are appropriately tracked, including date of receipt, and that 

invoices are reconciled with vendor records and paid in a timely manner. 

Concur Target Completion Date: May 31, 2011 

Facility’s Response: 

Fee Chief will coordinate and communicate with MH COTR to ensure 

invoices are tracked and documented as the invoices are initially received 

and certified/reconciled with vendor records as appropriate for payment by 

the SL COTR. The SL MH COTR or designee will develop a cover sheet 

that contains the information described herein and forwarded to the Fee 

Chief to ensure accuracy of information and timely payment. 

Purchased Care will process payments authorized by the COTR within 

20 days of receipt of the valid invoice in the Purchased Care Unit. The 

Cover Sheet will be annotated with the date of receipt in Purchased Care 

and will be maintained in accordance with records control requirements. 

Recommendation 4. We recommended that the VISN Director, in 

conjunction with the Medical Center Director, require that Fiscal Service 

ensure that properly obligated HCHV funds are not defunded. 

Concur Target Completion Date: Completed 

Facility’s Response: 

During the End of Year close-out process, Service Line Managers are 

required to review each obligation to ensure funding is committed by any 

outstanding invoices. Financial Management conducts a review of 

unliquidated balances on each obligation to prevent the loss of expired 

funds and requests justification from each Service Line. HCHV program 

was inadvertently included in this review. Financial Management was 

notified of the error in early October, funds were restored, and the 

obligation was increased on October 14, 2009. 

Financial Management has implemented steps to prevent this from 

reoccurring by instituting a Specific Purpose funding tracking system to 

ensure all special program funds are monitored for appropriate funding, 

timely obligations, and for review of any requests to the Program Office for 

additional funds or return of excess funds. 

VA Office of Inspector General 21 
Electronic Waiting List Management for Mental Health Clinics, Atlanta VA Medical Center, Atlanta, GA 

Appendix C

OIG Contact and Staff Acknowledgments
 

OIG Contact	 For more information about this report, please contact the 

Office of Inspector General at (202) 461-4720. 

Acknowledgments	 Victoria Coates, LICSW 

Darlene Conde-Nadeau, NP 

Thomas Seluzicki, CPA 

Michael Shepherd, MD 

VA Office of Inspector General 22 
Electronic Waiting List Management for Mental Health Clinics, Atlanta VA Medical Center, Atlanta, GA 

Appendix D

Report Distribution
 

VA DistributionVA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VA Southeast Network (10N7) 

Director, Atlanta VA Medical Center (508/00) 

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: Saxby Chambliss, Johnny Isakson 

U.S. House of Representatives: Hank Johnson Jr., John Lewis, Tom Price, David Scott, 

Rob Woodall 

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

VA Office of Inspector General 23