Department of Veterans Affairs

Office of Inspector General

Office of Healthcare Inspections
 

Report No. 11-01406-14

Community Based Outpatient
 

Clinic Reviews
 

Bennington, VT and Littleton, NH
 

Jamestown and Lackawanna, NY
 

Hagerstown, MD and Petersburg, WV
 

November 1, 2011
 

Washington, DC 20420
 
Why We Did This Review

The VA Office of Inspector General (OIG) is undertaking a systematic review of 

the Veterans Health Administration’s (VHA’s) community-based outpatient clinics 

(CBOCs) to assess whether CBOCs are operated in a manner that provides 

veterans with consistent, safe, high-quality health care. 

The Veterans’ Health Care Eligibility Reform Act of 1996 was enacted to equip 

VA with ways to provide veterans with medically needed care in a more 

equitable and cost-effective manner. As a result, VHA expanded the 

Ambulatory and Primary Care Services to include CBOCs located throughout the 

United States. CBOCs were established to provide more convenient access to 

care for currently enrolled users and to improve access opportunities within 

existing resources for eligible veterans not currently served. 

Veterans are required to receive one standard of care at all VHA health care 

facilities. Care at CBOCs needs be consistent, safe, and of high quality, 

regardless of model (VA-staffed or contract). CBOCs are expected to comply 

with all relevant VA policies and procedures, including those related to quality, 

patient safety, and performance. 

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)
Bennington, Littleton, Jamestown, Lackawanna, Hagerstown, and Petersburg 

Glossary
 AED 

BI-RADS 

BLS 

C&P 

CBOC 

COTR 

CPRS 

CT 

DX & TX Plan 

ECMS 

ED 

EKG 

EOC 

FPPE 

FTE 

FY 

HCS 

IT 

JC 

LCSW 

MedMgt 

MH 

MRI 

MST 

NP 

PA 

PCMM 

PCP 

PET 

PII 

PTSD 

Qtr 

TX 

VAMC 

VHA 

VISN 

VistA 

automated external defibrillator 

Breast Imaging Reporting and Data System 

Basic Life Support 

credentialing and privileging 

community based outpatient clinic 

Contracting Officer’s Technical Representative 

Computerized Patient Record System 

Computerized Tomography 

Diagnosis & Treatment Plan 

Executive Committee of the Medical Staff 

emergency department 

electrocardiogram 

environment of care 

Focused Professional Practice Evaluation 

full-time employee equivalents 

fiscal year 

Health Care System 

information technology 

Joint Commission 

Licensed Clinical Social Worker 

medication management 

mental health 

Magnetic Resonance Imaging 

military sexual trauma 

nurse practitioner 

physician assistant 

Primary Care Management Module 

primary care provider 

Positron Emission Tomography 

personally identifiable information 

Post-Traumatic Stress Disorder 

quarter 

treatment 

VA Medical Center 

Veterans Health Administration 

Veterans Integrated Service Network 

Veterans Health Information Systems and Technology 

Architecture 

VA OIG Office of Healthcare Inspections 
Bennington, Littleton, Jamestown, Lackawanna, Hagerstown, and Petersburg 

Table of Contents
 

Page
 

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

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

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

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

CBOC Characteristics................................................................................................ 3
 

Results and Recommendations................................................................................ 4
 

MH Continuity of Care............................................................................................. 4
 

Short-Term Fee Basis Care .................................................................................... 6
 

Women’s Health...................................................................................................... 9
 

C&P ........................................................................................................................ 13
 

Skills Competency .................................................................................................. 14
 

Environment and Emergency Management............................................................ 16
 

PCMM..................................................................................................................... 18
 

CBOC Contract....................................................................................................... 19
 

Appendixes

A. VISN 1 Director Comments ............................................................................... 22
 

B. White River Junction VAMC Director Comments............................................... 23
 

C. VISN 2 Director Comments ............................................................................... 29
 

D. VA Western New York HCS Director Comments .............................................. 30
 

E. VISN 5 Director Comments ............................................................................... 34
 

F. Martinsburg VAMC Director Comments............................................................. 35
 

G. OIG Contact and Staff Acknowledgments......................................................... 41
 

H. Report Distribution............................................................................................. 42
 

VA OIG Office of Healthcare Inspections 
Bennington, Littleton, Jamestown, Lackawanna, Hagerstown, and Petersburg 

Executive Summary
 

Purpose: We conducted an inspection of six CBOCs during the week of 

August 29, 2011. We evaluated select activities to assess whether the CBOCs 

operated in a manner that provides veterans with consistent, safe, high-quality health 

care. Table 1 lists the sites inspected. 

VISN Facility CBOC

1 White River Junction VAMC Bennington 

Littleton 

2 VA Western New York HCS Jamestown 

Lackawanna 

5 Martinsburg VAMC Hagerstown 

Petersburg 

Table 1. Sites Inspected

Recommendations: The VISN and Facility Directors, in conjunction with the 

respective CBOC managers, should take appropriate actions to: 

White River Junction VAMC 

	 Develop a plan for the Bennington CBOC that defines how MH emergencies that 

require a higher level of care are addressed. 

	 Identify at least one accessible VA or community-based ED where veterans at the 

Littleton CBOC are directed to seek emergent care when necessary. 

	 Develop a local policy for Short-Term Fee Basis consults at the White River Junction 

VAMC. 

	 Ensure that Short-Term Fee Basis consults at the Littleton CBOC are approved no 

later than 10 days from the date the consult was initiated. 

	 Ensure that Short-Term Fee Basis consults at the Bennington and Littleton CBOCs 

are approved by appropriate leadership or designee in accordance with VHA policy. 

	 Ensure that patients at the Bennington and Littleton CBOCs receive written 

notification when a Short-Term Fee Basis consult is approved. 

	 Ensure that the copies of Short-Term Fee Basis reports for the Bennington CBOC 

patients are filed or scanned into the medical record. 

	 Ensure that the ordering providers, or surrogate practitioners, at the Bennington 

CBOC communicate the Short-Term Fee Basis results to the patient within 14 days 

from the date the results are made available to the ordering provider. 

VA OIG Office of Healthcare Inspections i 
CBOC Names 

	 Establish a process at the Bennington and Littleton CBOCs to ensure effective 

oversight of the mammography program, as required by VHA policy. 

	 Ensure that all mammography results at the Bennington and Littleton CBOCs are 

documented using the BI-RADS code categories. 

	 Establish a process to ensure that patients at the Bennington and Littleton CBOCs 

are notified of mammogram results within the allotted timeframes and that 

notification is documented in the medical record. 

	 Ensure fee basis mammography results are filed or scanned into CPRS at the 

Bennington and Littleton CBOCs. 

	 Establish a process at the Bennington and Littleton CBOCs to ensure CPRS 

mammogram radiology orders are entered for all fee-basis mammograms and that 

all breast imaging and mammography results are linked to the appropriate radiology 

mammogram or breast study order. 

	 Ensure that the Bennington CBOC appoints a Women’s Health Liaison and that 

collaboration occurs with the parent facility’s Women Veterans Program Manager. 

	 Ensure that the Women’s Health Liaison at the Littleton CBOC collaborates with the 

Women Veterans Program Manager. 

	 Require that the competency policy includes what actions are taken when staff 

cannot demonstrate competency at the Bennington and Littleton CBOCs. 

	 Ensure that core competencies for the ancillary clinical staff at Bennington and 

Littleton CBOCs are defined. 

	 Ensure that all patient care staff members at the Littleton CBOC are trained in BLS 

with the use of an AED. 

	 Ensure that initial and annual competencies at the Bennington CBOC are assessed 

and documented. 

	 Ensure that the PCMM data is accurate in accordance with the VHA directive and 

specifically includes FTE for contract PCPs and Associate Physicians at the Littleton 

CBOC. 

	 Require that the Contracting Officer ensures the contract is modified to clearly define 

the requirements for payment and specifically how the contractor is to be 

compensated when patients are disenrolled. 

	 Require that the Contracting Officer ensures all contracts include a detailed 

description of performance measures and monitoring procedures that will be utilized 

VA OIG Office of Healthcare Inspections ii 
CBOC Names 

to evaluate the contractor’s performance and include enforcement provisions if those 

measures are not met. 

	 Strengthen the invoice validation process to ensure the accuracy of invoiced 

enrollees, using VA data as the basis for determining the payment due to the 

contractor. 

	 Determine, with the assistance of the Regional Counsel, the extent and collectability 

of the overpayments on the contract. 

VA Western New York HCS 

	 Develop a plan for the Jamestown and Lackawanna CBOCs that defines how MH 

emergencies that require a higher level of care are addressed. 

	 Ensure that patients at the Lackawanna CBOC receive written notification when a 

Short-Term Fee Basis consult is approved. 

	 Ensure that ordering practitioners, or surrogate practitioners, at the Lackawanna 

CBOC communicate the Short-Term Fee Basis results to the patient within 14 days 

from the date the results are made available to the ordering provider. 

	 Establish a process at the Jamestown and Lackawanna CBOCs to ensure patients 

with normal mammograms are provided written notification of results within the 

allotted timeframe and that notification is documented in the medical record. 

	 Establish a process at the Lackawanna CBOC to ensure CPRS mammogram 

radiology orders are entered for all fee-basis mammograms and that all breast 

imaging and mammography results are linked to the appropriate radiology 

mammogram or breast study order. 

	 Ensure that FPPEs at the Jamestown and Lackawanna CBOCs have clearly defined 

timeframes and that results are reported to the ECMS, documented in the ECMS 

minutes, and placed in the provider profiles. 

	 Require that all LCSWs at the Lackawanna CBOC have scopes of practice that are 

facility, service, and provider-specific. 

	 Ensure that all patient care staff members at the Lackawanna CBOC are trained and 

assessed for BLS and phlebotomy competency on an annual basis as required by 

local policy. 

	 Ensure that clinical competencies at the Lackawanna CBOC are assessed by an 

individual who has the appropriate clinical background and a current assessment of 

clinical skills. 

	 Allocate handicap parking spaces at the Lackawanna CBOC. 

VA OIG Office of Healthcare Inspections iii 
CBOC Names 

	 Ensure that the identified fire and life safety issues at the Lackawanna CBOC are 

corrected. 

	 Ensure that the invoice validation process for the Jamestown and Lackawanna 

CBOCs includes a review of the accuracy of contracted capitated rates presented on 

the invoices. 

	 Require that the Contracting Officer ensures the contract clearly states the 

requirements for payment and that all actionable terms are clearly defined for the 

Jamestown and Lackawanna CBOCs. 

Martinsburg VAMC 

	 Develop a local policy for Short-Term Fee Basis consults at the Martinsburg VAMC. 

	 Ensure providers at the Hagerstown CBOC document a justification for the use of 

Short-Term Fee Basis care in the medical record. 

	 Ensure that Short-Term Fee Basis consults at the Hagerstown and Petersburg 

CBOCs are approved no later than 10 days from the date the consult was initiated. 

	 Ensure that Short-Term Fee Basis consults at the Hagerstown and Petersburg 

CBOCs are approved by appropriate leadership or designee in accordance with 

VHA policy. 

	 Ensure that patients at the Hagerstown and Petersburg CBOCs receive written 

notification when a Short-Term Fee Basis consult is approved. 

	 Ensure that the copies of Short-Term Fee Basis reports for Hagerstown CBOC 

patients are filed or scanned into the medical record. 

	 Ensure that ordering practitioners, or surrogate practitioners, at the Hagerstown 

CBOC review Short-Term Fee Basis reports within 14 days from the date on which 

the results are available. 

	 Ensure that ordering practitioners, or surrogate practitioners, at the Hagerstown 

CBOC communicate Short-Term Fee Basis results to patients within 14 days from 

the date the results are made available to the ordering provider. 

	 Ensure that all mammography results at the Hagerstown CBOC are documented 

using the BI-RADS code categories. 

	 Establish and monitor a process at the Hagerstown and Petersburg CBOCs to 

ensure timely notification of normal mammography results to patients. 

	 Ensure that the PSB grants privileges consistent with the services provided at the 

Hagerstown CBOC. 

VA OIG Office of Healthcare Inspections iv 
CBOC Names 

	 Initiate FPPEs for all newly hired licensed independent practitioners at the 

Hagerstown CBOC. 

	 Ensure that non-licensed independent practitioners’ scopes of practice accurately 

reflect their specialty practices at the Hagerstown CBOC. 

	 Ensure that the entrance door at the Petersburg CBOC is ADA accessible. 

	 Maintain the security of patients’ PII at the Hagerstown and Petersburg CBOCs. 

	 Maintain auditory privacy during the check-in process at the Hagerstown CBOC. 

	 Ensure the Chief of OI&T evaluates the use of the IT closet at the Petersburg CBOC 

and implements appropriate measures in accordance with VA policy. 

	 Secure floor model sharps containers at the Hagerstown CBOC. 

	 Ensure an AED is available at the Petersburg CBOC. 

	 Ensure that the Contracting Officer considers utilizing a 12-month vesting criteria for 

future contracts to ensure a more effective use of VHA healthcare resources. 

	 Require that the Contracting Officer ensures pricing for all ancillary charges are 

identified in the contract. 

	 Require that the Contracting Officer ensures competition in the solicitation process 

by giving all bidders the opportunity to bid on the same requirements, specifically 

when changes are made after the solicitation has closed. 

Comments

The VISN and facility Directors agreed with the CBOC review findings and 

recommendations and provided acceptable improvement plans. (See Appendixes A–F, 

pages 22–36 for the full text of the Directors’ comments.) We will follow up on the 

planned actions until they are completed. 

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

Assistant Inspector General for
 

Healthcare Inspections
 

VA OIG Office of Healthcare Inspections v 
Bennington, Littleton, Jamestown, Lackawanna, Hagerstown, and Petersburg 

Objectives and Scope

Objectives. The purposes of this review are to: 

 Determine whether CBOCs comply with the standards according to VHA policy in 

the management of MH emergencies.1 

 Assess Short-Term Fee Basis authorization and follow up processes for outpatient 

radiology consults (CT, MRI, PET scan, and mammography) in an effort to ensure 

quality and timeliness of patient care in CBOCs. 

 Determine whether CBOCs comply with selected VHA requirements regarding the 

provision of mammography services for women veterans. 

 Determine whether CBOC providers are appropriately credentialed and privileged in 

accordance with VHA policy.2 

 Determine whether CBOCs have well-developed competency assessment and 

validation programs in place for skill specific competencies. 

 Determine whether CBOCs are in compliance with standards of operations 

according to VHA policy in the areas of environmental safety and emergency 

planning.3 

 Determine whether the CBOC primary care and MH contracts were administered in 

accordance with contract terms and conditions. 

 Determine whether primary care active panel management and reporting are in 

compliance with VHA policy.4 

Scope. The topics discussed in this report include: 

 MH Continuity of Care 

 Short-Term Fee Basis Care 

 Women’s Health 

 C&P 

 Skills Competency 

 Environment and Emergency Management 

1 VHA Handbook 1160.1, Uniform Mental Health Services in VA Medical Centers and Clinics, September 11, 2008.
 2 VHA Handbook 1100.19, Credentialing and Privileging, November 14, 2008.
 3 VHA Handbook 1006.1, Planning and Activating Community-Based Outpatient Clinics, May 19, 2004.
 4 VHA Handbook 1101.02, Primary Care Management Module (PCMM), April 21, 2009.
 

VA OIG Office of Healthcare Inspections 1 
Bennington, Littleton, Jamestown, Lackawanna, Hagerstown, and Petersburg 

 PCMM 

 Contracts 

For detailed information regarding the scope and methodology of the focused topic 

areas conducted during this inspection, please refer to Report No. 11-01406-177 

Informational Report Community Based Outpatient Clinics Cyclical Report FY 2011, 

May 31, 2011. This report is available at http://www.va.gov/oig/publications/reportslist.asp. 

We conducted the inspection in accordance with Quality Standards for Inspection and 

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

VA OIG Office of Healthcare Inspections 2 
Bennington, Littleton, Jamestown, Lackawanna, Hagerstown, and Petersburg 

CBOC Characteristics
 We formulated a list of CBOC characteristics that includes identifiers and descriptive information. Table 2 displays the inspected 

CBOCs and specific characteristics. 

Bennington Littleton Jamestown Lackawanna Hagerstown Petersburg

VISN 1 1 2 2 5 5 

Parent Facility White River Junction 

VAMC 

White River Junction 

VAMC 

VA Western New York 

HCS 

VA Western New York 

HCS 

Martinsburg VAMC Martinsburg VAMC 

Type of CBOC VA Contract Contract Contract VA Contract 

Number of Uniques,5

FY 2010

1,802 2,659 1,711 2,712 4,644 944 

Number of Visits, FY

2010

10,602 8,177 7,852 8,577 19,425 5,032 

CBOC Size6 Mid-Size Mid-Size Mid-Size Mid-Size Mid-Size Small 

Locality Rural Rural Rural Urban Urban Rural 

FTE PCP 1.84 ***7 2.00 2.80 4.60 0.65 

FTE MH 1.70 0.50 2.0 1.0 1.90 1.0 

Types of Providers PCP 

NP 

Psychiatrist 

LCSW 

PCP 

NP 

PCP 

NP 

LCSW 

PCP 

NP 

PA 

LCSW 

PCP 

NP 

PA 

PCP 

PA 

LCSW 

Specialty Care

Services Onsite

Yes No No No Yes Yes 

Tele-Health Services None None Tele-Retinal 

Tele-Nutrition 

Tele-Psychiatry 

Tele-Retinal 

Tele-Nutrition 

Tele-Psychiatry 

Tele-Retinal None 

Ancillary Services

Provided Onsite

Laboratory 

EKG 

Laboratory 

EKG 

Laboratory 

EKG 

Laboratory 

EKG 

Laboratory 

EKG 

Laboratory 

Pharmacy 

Radiology 

EKG 

Table 2. CBOC Characteristics

5 http://vaww.pssg.med.va.gov
 6 Based on the number of unique patients seen as defined by the VHA Handbook 1160.01, the size of the CBOC facility is categorized as very large (> 10,000), large
 

(5,000-10,000), mid-size (1,500-5,000), or small (< 1,500).

7 The White River Junction VAMC did not track FTEs for contract PCPs.
 

VA OIG Office of Healthcare Inspections 3 
Bennington, Littleton, Jamestown, Lackawanna, Hagerstown, and Petersburg 

Results and Recommendations
 

MH Continuity of Care

According to VHA policy, healthcare facilities need to have professional oversight of the 

delivery of MH care in associated CBOCs.8 Also, there must be methods and 

procedures for ensuring communication between the leadership of MH services and the 

associated CBOCs. This requirement for oversight and communication is intended to 

ensure the ability of the CBOCs to respond to patients’ MH needs. 

Required MH services vary according CBOC size, which is determined by the number 

of unique veterans the CBOC serves annually. Very large and large CBOCs are 

required to provide general and specialty MH services when these are needed. Large 

CBOCs must provide a substantial component of the MH services required by their 

patients either onsite or by tele-mental health, but they may supplement these services 

by referrals to geographically accessible VA facilities, through sharing agreements, 

contracts, or fee basis mechanisms. Mid-sized CBOCs must provide general MH 

services, if needed by their patients, utilizing tele-mental health as necessary. Specialty 

services must be available to those who require them by using on-site services, sharing 

agreements, contracts, or referrals, as well as tele-mental health or fee basis. Smaller 

CBOCs are to provide access to the full range of general and specialty MH services to 

those who require them through on-site services, referrals, contracts, or fee basis, as 

well as tele-mental health. 

General MH services include diagnostic and treatment planning evaluations for the full 

range of MH problems, treatment services using evidence-based pharmacotherapy or 

evidence-based psychotherapy, patient education, family education, referrals as needed 

to inpatient and residential care programs, and consultations about special emphasis 

problems. Specialty MH services include consultation and treatment services for the full 

range of MH conditions, which include evidence-based psychotherapy; MH intensive 

case management; psychosocial rehabilitation services including family education, skills 

training, and peer support; compensated work therapy and supported employment; 

PTSD teams or specialists; MST special clinics; homeless programs; and specialty 

substance abuse treatment services. Table 3 displays the MH Characteristics for each 

CBOC reviewed. 

8 VHA Handbook 1160.01. 

VA OIG Office of Healthcare Inspections 4 
Bennington, Littleton, Jamestown, Lackawanna, Hagerstown, and Petersburg 

Mental Health CBOC Characteristics

Bennington Littleton Jamestown Lackawanna Hagerstown Petersburg

Provides MH

Services

Yes Yes Yes Yes Yes Yes 

Number of MH

Uniques, FY

2010

386 210 301 243 719 97 

Number of MH

Visits

3,036 2,044 1,351 1,602 2,339 658 

General MH

Services

Dx & TX Plan 

MedMgt 

Psychotherapy 

PTSD 

MST 

MedMgt 

PTSD 

Dx & TX Plan 

MedMgt 

Psychotherapy 

PTSD 

MST 

Dx & TX Plan 

MedMgt 

Psychotherapy 

PTSD 

MST 

Dx & TX Plan 

MedMgt 

Psychotherapy 

Psychotherapy 

PTSD 

Specialty MH

Services

Consult & TX 

Psychotherapy 

Social Skills 

Peer Support 

PTSD 

Homeless Prgm 

Specialty Substance 

Abuse TX 

N/A Consult & TX 

Psychotherapy 

Social Skills 

Consult & TX 

Psychotherapy 

Social Skills 

Consult & TX N/A 

Tele-Mental

Health

Yes Yes Yes Yes Yes No 

MH Referrals Another VA Facility Another VA Facility Another VA Facility Another VA Facility Another VA Facility Another VA Facility 

Table 3. MH Characteristics for CBOCs

VA OIG Office of Healthcare Inspections 5 
Bennington, Littleton, Jamestown, Lackawanna, Hagerstown, and Petersburg 

Emergency Plan 

Facilities must comply with VHA policy, which outlines specific requirements for MH 

care at CBOCs.9 All CBOCs and facilities without an ED or 24/7 urgent care must have 

predetermined plans for responding to MH emergencies during times of operation. 

Table 4 shows the areas reviewed for this topic. 

Noncompliant Areas Reviewed

Bennington 

Littleton 

Jamestown 

Lackawanna 

The facility has identified in a pre-determined plan at least one 

accessible VA or community-based ED where veterans are 

directed to seek emergent care when necessary. 

The facility has developed contracts, sharing agreements, or 

other appropriate arrangements with the external organization for 

sharing information. 

The facility has developed financial arrangements for payment for 

authorized emergency services and necessary subsequent care. 

There is documentation in CPRS of the ED visit. 

There are recommendations documented for follow-up care in 

accordance with local policy. 

The recommendations were implemented and documented in the 

medical records in accordance with local policy. 

Table 4. MH Continuity of Care

VISN 1, White River Junction VAMC – Bennington and Littleton

Emergency Plan. The Bennington CBOC did not have a plan identified in their local 

policy addressing how MH emergencies would be addressed during the hours of 

operations if the provider determined that the patient requires a higher level of care. 

The MH emergency plan for the Littleton CBOC did not identify a VA or communitybased ED where veterans are directed to seek care during the hours of operations if the 

provider determined that the patient requires a higher level of care. 

VISN 2, VA Western New York HCS – Jamestown and Lackawanna

Emergency Plan. The Jamestown and Lackawanna CBOCs did not have a plan 

addressing how MH emergencies are to be addressed during the hours of operation if 

the provider determined that the patient requires a higher level of care. 

Short-Term Fee Basis Care

The Fee Program assists veterans who cannot easily receive care at a VAMC. The 

program pays the medical care costs of eligible veterans who receive care from non-VA 

9 VHA Handbook 1160.01. 

VA OIG Office of Healthcare Inspections 6 
Bennington, Littleton, Jamestown, Lackawanna, Hagerstown, and Petersburg 

providers when the VAMCs are unable to provide specific treatments or provide 

treatment economically because of their geographical inaccessibility. Fee Basis care 

may include dental services; outpatient, inpatient, and emergency care; and medical 

transportation. 

We evaluated if VA providers appropriately ordered and followed up on outpatient 

radiology procedures (CT, MRI, PET scan, and mammography). Table 5 shows the 

areas reviewed for this topic. The facilities identified as noncompliant needed 

improvement. Details regarding the findings follow the table. 

Noncompliant Areas Reviewed

Bennington 

Littleton 

Hagerstown 

Petersburg 

The facility has local policies and procedures regarding non-VA care 

and services purchased by authority that describe the request, 

approval, and authorization process for such services.10 

Hagerstown The provider documented a justification for using Fee Basis status 

in lieu of providing staff treatment as required by VHA policy.11 

Littleton 

Hagerstown 

Petersburg 

The date the consult was approved does not exceed 10 days from 

the date the consult was initiated. 

Bennington 

Littleton 

Hagerstown 

The non-VA care referral requests for medical, dental, and ancillary 

services were approved by the Chief of Staff, Clinic Chief, Chief 

Medical Administration Services, or an authorized designee.12 

Bennington 

Littleton 

Lackawanna 

Hagerstown 

Petersburg 

Patients were notified of consult approvals in writing as required by 

VHA policy.13 

Bennington 

Hagerstown 

A copy of the imaging report is in CPRS according to VHA policy.14 

Hagerstown There is evidence the ordering provider or surrogate practitioner 

reviewed the report within 14 days from the date on which the 

results are available to the ordering practitioner. 

10 VHA Handbook 1160.01; VHA Chief Business Office Policy 1601F, Fee Services,
 

http://vaww1.va.gov/cbo/apps/policyguides/index.asp; VHA Handbook 1907.01, Health Information Management
 

and Health Records, August 25, 2006; and VHA Manual M-1, PART I, Chapter 18, Outpatient Care – Fee, July 20,
 

1995.
 11 VHA Handbook 1907.01.
 12 VHA Chief Business Office Policy 1601F.
 13 VHA Manual M-1, PART I, Chapter 18.
 14 VHA Handbook 1907.01.
 

VA OIG Office of Healthcare Inspections 7 
Bennington, Littleton, Jamestown, Lackawanna, Hagerstown, and Petersburg 

Noncompliant Areas Reviewed (continued)

Bennington 

Lackawanna 

Hagerstown 

There is evidence the ordering provider or other licensed healthcare 

staff member informed the patient about the report within 14 days 

from the date on which the results are available to the ordering 

practitioner.15 

Table 5. Short-Term Fee Basis

VISN 1, White River Junction VAMC – Bennington and Littleton

There were eight patients who received services through a Short-Term Fee Basis 

consult at the Bennington CBOC and one patient at the Littleton CBOC. 

Policy. The White River Junction VAMC did not have a local policy for Short-Term Fee 

Basis consults. 

Consult Approval Date. At the Littleton CBOC, the date the consult was approved 

exceeded 10 days from the date the consult was initiated. 

Consult Approval Process. We found that the consults in seven of eight records at the 

Bennington CBOC and the one consult at the Littleton CBOC were not approved 

according to VHA policy. 

Patient Consult Notifications. We found that five of eight patients at the Bennington 

CBOC and the patient at the Littleton CBOC were not notified in writing of consult 

approvals. 

Medical Record. A copy of the Short-Term Fee Basis imaging report was not found in 

three of eight medical records at the Bennington CBOC. 

Communication of Results. We found no evidence in the medical record that three of 

eight patients at the Bennington CBOC were informed about the results within 14 days 

from the date on which the results were available. 

VISN 2, VA Western New York HCS – Jamestown and Lackawanna

There was one patient who received services through a Short-Term Fee Basis consult 

at the Lackawanna CBOC. No patients at the Jamestown CBOC met the criteria for this 

review. 

Patient Consult Notifications. At the Lackawanna CBOC, we found that the patient had 

not been notified in writing of the approval of the Short-Term Fee Basis consult. 

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

VA OIG Office of Healthcare Inspections 8 
Bennington, Littleton, Jamestown, Lackawanna, Hagerstown, and Petersburg 

Communication of Results. We found no evidence in the medical record that the patient 

at the Lackawanna CBOC was informed of the results within 14 days from the date the 

results were available. 

VISN 5, Martinsburg VAMC – Hagerstown and Petersburg

There were 14 patients from the Hagerstown CBOC and 1 patient from the Petersburg 

CBOC who received services through a Short-Term Fee Basis consult. 

Policy. The Martinsburg VAMC did not have a local policy for Short-Term Fee Basis 

consults. 

Fee Basis Justification. The providers at the Hagerstown CBOC did not document a 

justification for the consult in CPRS in 7 of 14 records. 

Consult Approval Date. We found that 9 of 14 consults at the Hagerstown CBOC and 

the 1 consult at the Petersburg CBOC were not approved within 10 days from the date 

the consult was initiated. 

Consult Approval Process. We found that 9 of 14 consults at the Hagerstown CBOC 

were not approved in accordance with VHA policy. 

Patient Consult Notifications. We found that the patients at the Hagerstown and 

Petersburg CBOCs who received services through Short Term Fee Basis consults did 

not receive written notification of the consult approval. 

Report Review. We found no evidence in 5 of 14 medical records at the Hagerstown 

CBOC that the ordering provider or surrogate practitioner reviewed the report within 

14 days from the date on which the results were available. 

Communication of Results. We found no evidence in the medical record that 9 patients 

at the Hagerstown CBOC were informed about the results within 14 calendar days from 

the date on which the results were available. 

Women’s Health Review

Each VHA facility must ensure that eligible women veterans have access to 

comprehensive medical care, including care for gender-specific conditions and MH 

conditions, that is comparable to care provided for male veterans.16 All eligible and 

enrolled women veterans, irrespective of where they obtain care in VHA, must have 

access to all necessary services as clinically indicated. 

16 VHA Handbook 1330.01, Healthcare Services for Women Veterans, May 21, 2010. 

VA OIG Office of Healthcare Inspections 9 
Bennington, Littleton, Jamestown, Lackawanna, Hagerstown, and Petersburg 

Quality of Care Measures17 

Breast cancer is the second most common type of cancer among American women, 

with approximately 207,000 new cases reported each year.18 Timely screening, 

diagnosis, notification, interdisciplinary treatment planning, and treatment are essential 

to early detection, appropriate management, and optimal patient outcomes. Screening 

by mammography (an x-ray of the breast) has been shown to reduce mortality by 

20–30 percent among women age 40 and older. 

VHA has established gender-specific performance measures in the facility and CBOCs. 

Breast cancer screening for women ages 50–69 is an ongoing CBOC preventive care 

performance measure. Table 6 shows a comparative of the parent facilities’ and the 

respective CBOCs’ scores. 

Measure 

Meets 

Target Facility 

Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 

(%) 

Mammography, 

50-69 years old 77% 405 White River Junction VAMC 25 32 71 

405GA Bennington CBOC 12 13 92 

405HC Littleton CBOC 13 17 76 

528 VA Western New York HCS 23 29 79 

528GB Jamestown CBOC 12 14 86 

528GQ Lackawanna CBOC 13 16 81 

613 Martinsburg VAMC 22 27 86 

613GB Hagerstown CBOC 20 23 87 

613GE Petersburg CBOC 5 5 100 

Table 6. Mammography Screening FY 2011 

Littleton CBOC. The White River Junction VAMC action plan for improving the 

mammogram performance measure included the chartering of a multidisciplinary 

prevention index team. The team completed a process map and developed and 

secured approval of their measures. They educated Primary Care and Patient Aligned 

Care Team members in the new process and are revising the facility’s mammogram 

protocol. 

Mammography Management 

All enrolled women veterans need to receive comprehensive primary care from a 

designated women’s health PCP who is interested and proficient in the delivery of 

comprehensive primary care to women, irrespective of where they are seen. 

17 Parent facility scores were obtained from http://vaww.pdw.med.va.gov/MeasureMaster/MMReport.asp Note:
 

Scores are weighted. The purpose of weighting is to correct for the over-representation of cases from small sites and
 

the under-representation of cases from large sites. Weighting can alter the raw measure score
 

(numerator/denominator). Sometimes the adjustment can be quite significant.
 18 American Cancer Society, Cancer Facts & Figures 2009.
 

VA OIG Office of Healthcare Inspections 10 
Bennington, Littleton, Jamestown, Lackawanna, Hagerstown, and Petersburg 

VHA policy maintains that the full scope of primary care is provided to all eligible 

veterans seeking ongoing health care.19 Therefore, regardless of the number of women 

veterans utilizing a particular facility, all sites that offer primary care services must offer 

comprehensive primary care to women veterans and all necessary gender specific 

services must be available at every facility and CBOC. Table 7 shows the areas 

reviewed for this topic. The facilities identified as noncompliant needed improvement. 

Details regarding the findings follow the table. 

Noncompliant Areas Reviewed

Patients are referred to mammography facilities that have current 

Food and Drug Administration or State-approved certifications. 

Bennington 

Littleton 

Hagerstown 

Mammogram results are documented using the American College 

of Radiology’s BI-RADS code categories.20 

The ordering VHA provider or surrogate was notified of abnormal or 

critical results within a defined timeframe. 

Bennington Patients with abnormal or critical results are notified within a defined 

timeframe. 

Bennington 

Littleton 

Jamestown 

Lackawanna 

Hagerstown 

Petersburg 

Patients receive written notice of normal mammogram results, and 

the notifications are documented in the patients’ medical record as 

required by VHA policy.21 

Bennington 

Littleton 

The facility has an established process for tracking results from 

mammograms performed off-site. 

Bennington 

Littleton 

Fee Basis mammography reports are scanned into VistA. 

Bennington 

Littleton 

Lackawanna 

All screening and diagnostic mammograms were initiated via an 

order placed into the VistA Radiology package.22 

Bennington Each CBOC has an appointed Women’s Health Liaison. 

Littleton There is evidence that the Women’s Health Liaison collaborates 

with the parent facility’s Women Veterans Program Manager on 

women’s health issues. 

Table 7. Mammography

19 VHA Handbook 1330.01.
 20 The American College of Radiology’s Breast Imaging Reporting and Database System is a quality assurance
 

guide designated to standardize breast imaging reporting and facilitate outcomes monitoring.

21 VHA Handbook 1330.01.
 22 VHA Handbook 1330.01.
 

VA OIG Office of Healthcare Inspections 11 
Bennington, Littleton, Jamestown, Lackawanna, Hagerstown, and Petersburg 

VISN 1, White River Junction VAMC – Bennington and Littleton

Monitoring of Mammography Services. The facility had not established an effective 

process for monitoring mammography services as required by VHA policy. Although 

the facility initiated a team to monitor mammography services, it was not using the most 

current VHA policies. The facility did not have contract sites for mammography and was 

unable to consistently track fee basis mammograms. 

Documentation of Results. Mammogram results were not documented using the 

American College of Radiology’s BI-RADS code categories in one of five records 

reviewed at the Bennington CBOC and one of three at the Littleton CBOC. 

Patient Notification of Mammography Results. We reviewed medical records of patients 

who had normal mammography results and determined that two of four at the 

Bennington CBOC and one of three patients at the Littleton CBOC were not notified 

within the required timeframe of normal results. We also found that the patient with 

abnormal result at the Bennington CBOC was not notified within the required timeframe 

of 14 days. 

Scanned Reports. We reviewed medical records at the Littleton CBOC of three patients 

who had mammograms performed at non-VA facilities under fee basis agreements. We 

determined that one of three patients’ mammogram results were not scanned into VistA. 

At the Bennington CBOC, four of five patients’ mammogram results were not scanned 

into VistA. 

Mammography Orders and Access. In four of five records at the Bennington CBOC and 

one of three records at the Littleton CBOC, providers did not enter CPRS mammogram 

radiology orders for fee base mammograms. Fee basis or contract agreements must be 

electronically entered as a CPRS radiology order. All breast imaging and 

mammography results must be linked to the appropriate radiology mammogram or 

breast study order. 

Appointment of Women’s Health Liaison. There was no formal appointment of a 

Women’s Health Liaison at the Bennington CBOC. At the Littleton CBOC, a liaison had 

been appointed; however, there was no evidence of collaboration with the Women 

Veterans Program Manager. 

VISN 2, VA Western New York HCS – Jamestown and Lackawanna

Patient Notification of Mammography Results. We reviewed medical records of patients 

who had normal mammography results and determined that one of two patients at the 

Jamestown CBOC and two of four patients at the Lackawanna CBOC were not notified 

of normal results within the required timeframe. 

Mammography Orders and Access. Providers at the Lackawanna CBOC did not enter 

CPRS mammogram radiology order for one of four patients. Fee basis or contract 

agreements must be electronically entered as a CPRS radiology order. All breast 

VA OIG Office of Healthcare Inspections 12 
Bennington, Littleton, Jamestown, Lackawanna, Hagerstown, and Petersburg 

imaging and mammography results must be linked to the appropriate radiology 

mammogram or breast study order. 

VISN 5, Martinsburg VAMC – Hagerstown and Petersburg

BI-RADS Documentation. At the Hagerstown CBOC, one of eight mammogram results 

were not documented using the American College of Radiology’s BI-RADS code 

categories. 

Patient Notification of Mammography Results. We reviewed medical records of patients 

who had normal mammography results and determined that six of eight patients at the 

Hagerstown CBOC and the one patient at the Petersburg CBOC were not notified within 

required timeframe. 

C&P

We reviewed C&P folders to determine whether facilities had consistent processes to 

ensure that providers complied with applicable requirements as defined by VHA 

policy.23 We reviewed nurse personnel files to ensure licensure and education were 

verified. Table 8 shows the areas reviewed for this topic. The facilities identified as 

noncompliant needed improvement. Details regarding the findings follow the table. 

Noncompliant Areas Reviewed

There was evidence of primary source verification for each 

provider’s license. 

Each provider’s license was unrestricted. 

There were two efforts made to obtain verification of clinical 

privileges (currently or most recently held at other institutions) for 

new providers. 

FPPEs for new providers outlined the criteria to be monitored. 

Hagerstown New providers’ FPPEs were implemented on first clinical start day. 

There was evidence that the provider was educated about FPPE 

prior to its initiation. 

Jamestown 

Lackawanna 

FPPE results were reported to the medical staff’s Executive 

Committee. 

Prior to the start of a new privilege, criteria for the FPPE were 

developed. 

Service Chief, Credentialing Board, and/or Medical Staff’s Executive 

Committee list documents reviewed and the rationale for 

conclusions reached for granting licensed independent practitioner 

privileges. 

Hagerstown Privileges granted to providers are facility, service, and provider 

specific.24 

23 VHA Handbook 1100.19. 24 VHA Handbook 1100.19. 

VA OIG Office of Healthcare Inspections 13 
Bennington, Littleton, Jamestown, Lackawanna, Hagerstown, and Petersburg 

Noncompliant Areas Reviewed (continued)

The determination to continue current privileges are based in part 

on results of Ongoing Professional Practice Evaluation activities. 

The Ongoing Professional Practice Evaluation and reappraisal 

process included consideration of such factors as clinical pertinence 

reviews and/or performance measure compliance. 

Relevant provider-specific data was compared to aggregated data 

of other providers holding the same or comparable privileges. 

Jamestown 

Lackawanna 

Hagerstown 

Scopes of practice are service and provider specific. 

There is documentation that the nurses’ licenses were verified. 

There is evidence that the nurses’ education was verified. 

Table 8. C&P

VISN 2, VA Western New York HCS – Jamestown and Lackawanna

FPPE. We reviewed the FPPEs of one newly hired physician at the Jamestown CBOC 

and two newly hired physicians at the Lackawanna CBOC and found they did not have 

clearly defined timeframes for the evaluation period. Further, we found no discussion of 

the results in the ECMS minutes or evidence of the FPPE results in the providers’ 

profiles. 

Scope of Practice. One LCSW at the Jamestown CBOC and one LCSW at the 

Lackawanna CBOC did not have a scope of practice. Scope of practice is a term used 

to describe activities that may be performed by health care workers. The scope of 

practice is specific to the individual and the facility involved. 

VISN 5, Martinsburg VAMC – Hagerstown and Petersburg

Clinical Privileges. The Professional Standards Board granted clinical privileges for 

procedures that were not performed at the Hagerstown CBOC. A provider was granted 

Internal Medicine core privileges, which included lumbar punctures and paracentesis. 

FPPE. A newly hired physician at the Hagerstown CBOC did not have a FPPE 

implemented on the first clinical start day. 

Scope of Practice. We reviewed the files of two PAs at the Hagerstown CBOC and 

found that the scope of practice for one of the providers did not include the provider’s 

MH specialty practices. 

Skills Competency

The JC requires that organizations define and verify staff qualifications and ensure that 

staff are competent to perform their responsibilities. Table 9 shows the areas reviewed 

for this topic. 

VA OIG Office of Healthcare Inspections 14 
Bennington, Littleton, Jamestown, Lackawanna, Hagerstown, and Petersburg 

Noncompliant Areas Reviewed

There is a policy that defines the competencies of the staff that 

provide patient care, treatment, or services at the CBOC. 

Lackawanna The policy defines who is responsible for competency validation and 

what the process is for selection of qualified personnel to assess 

and validate competence. 

Bennington 

Littleton 

The CBOC has a policy or process describing actions taken when 

staff cannot demonstrate competency. 

Bennington 

Littleton 

The facility has identified skill competencies for the CBOC. 

Bennington Staff competency was initially assessed and documented as a part 

of the CBOC orientation. 

Bennington 

Littleton 

Lackawanna 

Patient care staff identified skill competencies were validated and 

documented. 

Table 9. Skills Competency

VISN 1, White River Junction VAMC –Bennington and Littleton

Policy. The local competency policy does not describe actions taken when staff cannot 

demonstrate competency. 

Core Competencies. Ancillary clinical staff at the Bennington and Littleton CBOCs did 

not have defined core competencies. 

BLS. We found that two patient care staff at the Littleton CBOC did not have BLS 

certification that included AED training. Local policy states that all clinical staff 

members will maintain BLS for Healthcare Providers training, which includes the use of 

an AED. 

Staff Competency. The Bennington CBOC did not provide written documentation that 

staff competency was initially or annually assessed as required by local policy. 

VISN 2, VA Western New York HCS – Lackawanna

Core Competencies. We found that three of the patient care staff members reviewed at 

the Lackawanna CBOC did not have current phlebotomy training, and one of four staff 

members did not have current BLS training. These skills were identified by the facility 

as core competencies for these staff members, and local policy requires competencies 

to be assessed on an annual basis. 

Clinical Competency Assessment. We found that the assessment of clinical 

competencies was not consistently provided by qualified personnel. A non-clinical 

individual assessed staff members for clinical competencies. Additionally, a staff 

member who did not have a current phlebotomy competency assessed other staff 

members for their phlebotomy competency at the Lackawanna CBOC. 

VA OIG Office of Healthcare Inspections 15 
Bennington, Littleton, Jamestown, Lackawanna, Hagerstown, and Petersburg 

Environment and Emergency Management

EOC 

To evaluate the EOC, we inspected patient care areas for cleanliness, safety, infection 

control, and general maintenance. Table 10 shows the areas reviewed for this topic. 

The facilities identified as noncompliant needed improvement. Details regarding the 

findings follow the table. 

Noncompliant Areas Reviewed

Lackawanna There is handicap parking, which meets the ADA requirements. 

The CBOC entrance ramps meet ADA requirements. 

Petersburg The entrance door to the CBOC meets ADA requirements. 

Lackawanna The CBOC is well maintained (e.g., ceiling tiles clean and in 

good repair, walls without holes, etc.). 

The CBOC is clean (walls, floors, and equipment are clean). 

Hagerstown The patient care area is safe. 

Medical equipment is checked routinely (biomedicine tags when 

applicable). 

There is an alarm system or panic button installed in high-risk 

areas as identified by the vulnerability risk assessment. 

Hagerstown Privacy is maintained. 

Petersburg IT security rules are adhered to. 

Lackawanna 

Hagerstown 

Petersburg 

Patients’ PII is secured and protected. 

There is alcohol hand wash or a soap dispenser and sink 

available in each examination room. 

The sharps containers are less than 3⁄4 full. 

There is evidence of fire drills occurring at least annually. 

Fire extinguishers are easily identifiable. 

The CBOC collects, monitors, and analyzes hand hygiene data. 

Staff use two patient identifiers for blood drawing procedures. 

The CBOC is included in facility-wide EOC activities. 

Table 10. EOC

VISN 1, White River Junction VAMC – Bennington and Littleton

Due to Hurricane Irene and the damage inflicted in the surrounding community, the 

Bennington CBOC was closed and inaccessible for an on-site EOC inspection. We had 

no EOC findings at the Littleton CBOC. 

VA OIG Office of Healthcare Inspections 16 
Bennington, Littleton, Jamestown, Lackawanna, Hagerstown, and Petersburg 

VISN 2, VA Western New York HCS – Lackawanna

Parking. The Lackawanna CBOC had two parking lots; however, neither lot had 

designated handicap parking spaces. There were two handicap parking spaces on the 

street in front of the CBOC; however, the spaces were not the property of the CBOC. 

Fire and Life Safety. The following fire hazards and safety issues were identified in the 

basement at the Lackawanna CBOC: (1) open ceilings, (2) standing water, (3) exposed 

hanging wires over medical records, and (4) multiple wall penetrations that included a 

firewall. 

VISN 5, Martinsburg VAMC – Hagerstown and Petersburg

Physical Access. The door handle at the Petersburg CBOC required a tight grasp to 

open. The ADA requires that facility doors be equipped with handles that are easy to 

grasp with one hand and do not require tight grasping, pinching, or twisting of the wrist 

to operate.25 

PII. We found that the transportation of laboratory specimens was not secured at the 

Hagerstown and Petersburg CBOCs. CBOC staff placed the specimens in unsecured 

containers, and a VA driver transported the specimens to the parent facility for 

processing. The specimens disclosed the patients’ names and social security numbers. 

The containers were unsecured; therefore, staff could not ensure the security of 

patients’ PII.26 

Auditory Privacy. The auditory privacy was inadequate for patients during the check-in 

process at the Hagerstown CBOC. Check-in staff communicated with patients through 

a sliding glass window in close proximity to other patients in the waiting area. There 

was signage present and an indicator on the floor instructing other patients to wait 

behind the line; however, staff did not ensure a zone of privacy was maintained. 

IT Security. At the Petersburg CBOC, we found the IT equipment was in a small closet 

that also contained a hot water heater. A risk assessment had not been conducted to 

determine if it was appropriate to have the water heater co-located with the IT 

equipment. According to VA policy, temperature and humidity within a computer room 

must be in a range compatible with the computer equipment specifications.27 

Sharps Containers. We found free standing sharps containers on the floor in the 

Hagerstown CBOC laboratory. The containers were not secured in a bracket, and the 

flip-top lids were open. This condition could result in a potential safety hazard if the 

containers were knocked over and spilled the contaminated needles and other contents. 

25 Americans with Disabilities Act.
 26 The Health Insurance Portability and Accountability Act (HIPAA), 1996.
 27 VHA Handbook 6500, Information Security Program, September 18, 2007.
 

VA OIG Office of Healthcare Inspections 17 
Bennington, Littleton, Jamestown, Lackawanna, Hagerstown, and Petersburg 

Emergency Management 

VHA policy requires each CBOC to have a local policy or standard operating procedure 

defining how medical emergencies, including MH, are handled.28 Table 11 shows the 

areas reviewed for this topic. 

Noncompliant Areas Reviewed

There is a local medical emergency management plan for this 

CBOC. 

The staff can articulate the procedural steps of the medical 

emergency plan. 

The CBOC clinical staff are trained in cardiopulmonary resuscitation 

with the use of an AED. 

Petersburg The CBOC has an AED onsite for cardiac emergencies. 

There is a local MH emergency management plan for this CBOC. 

The staff can articulate the procedural steps of the MH emergency 

plan. 

Table 11. Emergency Management

VISN 5, Martinsburg VAMC – Hagerstown and Petersburg

AED. An AED was not available at the Petersburg CBOC. The absence of an AED 

may lead to an undesirable clinical outcome in the event of an emergency. 

PCMM

We conducted reviews of the PCMM administration to assess VHA’s management of 

the primary care panels. VHA policy states that the PCMM Coordinator is responsible 

for ensuring that the information in the PCMM database is accurate and current.29 

Table 12 shows the areas reviewed for this topic. The CBOCs identified as 

noncompliant needed improvement. Details regarding the finding follow the table. 

Noncompliant Areas Reviewed

A system is in place to ensure patients are not assigned to a panel 

prior to being seen for their first appointment. 

The facility assigns a new patient to a panel after it has been 

confirmed that the patient is not assigned to a provider at another 

facility. 

Patients are identified for removal from the PCMM panel on a 

monthly basis (at a minimum). 

Panel sizes are reasonable compared to the PCMM guide of 1,200 

patients for a full-time PCP. 

28 VHA Handbook 1006.1.
 29 VHA Handbook 1101.02, Primary Care Management Module, April 21, 2009.
 

VA OIG Office of Healthcare Inspections 18 
Bennington, Littleton, Jamestown, Lackawanna, Hagerstown, and Petersburg 

Noncompliant Areas Reviewed (continued)

Littleton PCPs have been kept current in PCMM 

The number of patients invoiced is comparable to the total number 

of patients assigned to the PCP panels. 

Table 12. PCMM

VISN 1, White River Junction VAMC – Littleton

We noted that the facility does not track each provider’s time, expressed as FTE in 

PCMM, as required in the VHA handbook. The facility assigns patients to the provider’s 

panel but does not report FTEs for their contract sites. Workload and management 

efficiencies are distorted when FTEs for contract physicians are not reported. 

CBOC Contract

We conducted reviews of contracted primary care at the Littleton, Jamestown, 

Lackawanna, and Petersburg CBOCs to evaluate the effectiveness of VHA oversight 

and administration for selected contract provisions relating to quality of care and 

payment of services. VA professionals provide MH services at each of these CBOCs, 

either on-site or tele-mental health services. Each CBOC engagement included: (1) a 

review of the contract, (2) analysis of patient care encounter data, (3) corroboration of 

information with VHA data sources, (4) site visits, and (5) interviews with VHA and 

contractor staff. Our review focused on documents and records for the 1st Qtr, FY 2011. 

Table 13 summarizes the areas we reviewed and identifies the CBOCs that were not 

compliant in those areas. Details regarding the findings follow the table. 

Noncompliant Areas Reviewed

(1) Contract provisions relating to payment and quality of care: 

Littleton 

Jamestown 

Lackawanna 

Petersburg 

a. Requirements for payment. 

b. Rate and frequency of payment. 

c. Invoice format. 

Littleton d. Performance measures (including incentives/penalties). 

e. Billing the patient or any other third party. 

Petersburg (2) Technical review of contract modifications and extensions. 

Littleton 

Jamestown 

Lackawanna 

(3) Invoice validation process. 

(4) The COTR designation and training. 

(5) Contractor oversight provided by the COTR. 

(6) Timely access to care. 

Table 13. Review of PC and MH Contract Compliance

VA OIG Office of Healthcare Inspections 19 
Bennington, Littleton, Jamestown, Lackawanna, Hagerstown, and Petersburg 

VISN 1, White River Junction VAMC – Littleton

Requirements for Payment. The contract has conflicting language regarding payment 

terms for disenrolled veterans. The contract states the contractor is to receive full 

payment for a patient during the month of disenrollment only if the contractor treated the 

patient during that month; otherwise, the payment is to be prorated. However, a 

subsequent contract provision states the contractor will be paid for the full monthly 

capitated rate in the month that a patient disenrolled. 

Performance Measures. The contract does not contain a detailed description of 

performance measures or monitoring procedures used by White River Junction VAMC 

to ensure contract compliance, as required by VA Directive 1663.30 The contract states 

“the contractor is required to meet VHA quality criteria and performance measures, 

which will be available upon request” without specifically defining the criteria. 

Additionally, the contract does not have any incentives or penalties if performance 

exceeds or does not meet standards. 

Invoice Validation Process. The COTR validated approximately 10 percent of 

2,000 enrollees that are billed each month, which does not provide adequate assurance 

of validation and reduce the risk of overpayment. 

We found that the contractor had been overpaid for patients that did not meet eligibility 

criteria under the contract. Since VA relied on the contractor to remove ineligible 

patients and did not have an independent process to validate patient eligibility, the 

contractor was paid the monthly capitated rate for approximately 51 patients who in 

some cases never received care from the contractor. The overcharges of approximately 

$12,000 were calculated from the contract award month of July 2009 to October 2010. 

These overcharges could have been avoided if VA had an adequate validation process 

that relied on VA data to determine eligibility for payment. 

VISN 2, Western New York HCS – Jamestown

Invoice Validation Process. The COTR authorized payment of invoices that had an 

incorrect capitated rate, which resulted in underpayments of approximately $5,000 to 

the contractor. The contractor invoices for the period November 2010 through 

January 2011 contained capitated rates which were applicable to the prior contract 

period. 

Requirements for Payment. The contract does not clearly define the requirements for 

payment. The contract required that each patient have a qualifying visit every 

12 months to remain billable but does not define the term “qualifying visit.” 

30 VA Directive 1663, Health Care Resources Contracting – Buying, Title 38 U.S.C. 8153, August 10, 2006. 

VA OIG Office of Healthcare Inspections 20 
Bennington, Littleton, Jamestown, Lackawanna, Hagerstown, and Petersburg 

VISN 2, Western New York HCS – Lackawanna

Invoice Validation Process. The COTR authorized payment of invoices that had an 

incorrect capitated rate, which resulted in underpayments of approximately $18,000 to 

the contractor. Contractor invoices for the period November 2010 through June 2011 

contained capitated rates which were applicable to the prior contract period. 

Requirements for Payment. The contract does not clearly define the requirements for 

payment. The contract required that each patient have a qualifying visit every 

12 months to remain billable but does not define the term “qualifying visit.” 

VISN 5, Martinsburg VAMC – Petersburg

Requirements for Payment. The current contract payment terms for eligible enrollees 

results in excess contractor compensation. The terms for payment require that a patient 

receive a vesting visit at least once every 24 months to be eligible for the monthly 

capitated payment, while most CBOC contracts require a vesting visit at least once 

every 12 months. Requiring a vesting visit every 12 months instead of every 24 months 

would have saved VA as much as $22,000 or approximately 5 percent per year. 

The contract states the Contractor is to provide shingles vaccinations to all veterans and 

flu vaccinations to non-enrolled veterans at an additional cost, separate from the 

monthly capitated rate. However, the cost of these vaccinations is not stated in the 

contract. 

Technical Review. A seven-page amendment was made to the solicitation after the due 

date for offers, which could have affected competition for the contract. The amendment 

had significant changes, including a 50 percent increase in the contract amount and the 

removal of penalties for substandard performance. The solicitation was not reissued, 

and there is no evidence that the due date for proposals was extended. These changes 

were significant, and the solicitation should have been reissued for competition. 

Additionally, by removing performance penalties, VHA has little recourse to enforce 

VHA standards of care for substandard performance short of terminating the contract. 

VA OIG Office of Healthcare Inspections 21 
Bennington, Littleton, Jamestown, Lackawanna, Hagerstown, and Petersburg 

Appendix A

VISN 1 Director Comments

Department of

Veterans Affairs Memorandum

Date: October 19, 2011
 

From: Director, VISN 1 (10N1)
 

Subject: CBOC Reviews: Bennington, VT and Littleton, NH
 

To: Director, 54F Healthcare Inspections Division (54F)
 

Director, Management Review Service (VHA 10A4A4) 

I concur with the actions submitted to the Director of the 

Healthcare Inspection Division (54F) and the Director of 

Management Review Service regarding the CBOC reviews of the 

Bennington, VT and Littleton, NH CBOCs. 

VA OIG Office of Healthcare Inspections 22 
Bennington, Littleton, Jamestown, Lackawanna, Hagerstown, and Petersburg 

Appendix B

White River Junction VAMC Director Comments

Department of

Veterans Affairs Memorandum

Date: October 19, 2011 

From: Director, White River Junction VAMC (405/00) 

Subject: CBOC Review: Bennington, VT and Littleton, NH

To: Director, VISN 1 (10N1) 

This confirms that I concur with the comments (dated 10/14/11) submitted 

in response to the Office of Inspector General’s Report. 

(original signed by Danielle Ocker, Associate Director for:) 

Robert M. Walton 

Director 

VA OIG Office of Healthcare Inspections 23 
Bennington, Littleton, Jamestown, Lackawanna, Hagerstown, and Petersburg 

Comments to Office of Inspector General’s Report
 

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

to the Office of Inspector General’s report: 

OIG Recommendations

Recommendation 1. We recommended that a plan is developed to define how MH
 

emergencies that require a higher level of care are addressed at the Bennington CBOC.
 

Concur
 

Target date for completion: December 31, 2011
 

The existing CBOC standard operating procedure (SOP) will be revised to reflect a
 

more detailed referral process.
 

Recommendation 2. We recommended that at least one accessible VA or communitybased ED is identified where veterans are directed to seek emergent care when
 

necessary at the Littleton CBOC.
 

Concur
 

Target date for completion: January 31, 2012
 

The existing CBOC standard operating procedure (SOP) will be revised to reflect the
 

following:
 

Procedures for managing Mental Health emergencies: 

 WRJ VAMC will identify an accessible community-based Emergency Department 

where Veterans with emergent health care needs will be referred. 

 WRJ VAMC will develop agreements and arrangements for sharing information 

and financial payment with the identified community-based facility. 

	 While action plan in progress: If patient is considered to be at imminent risk of 

harm to self or others, immediately contact local emergency services (911 or 

other). Patient will be taken to the nearest facility capable of providing an 

emergency mental health evaluation. 

Recommendation 3. We recommended that the White River Junction VAMC develops 

a local policy for Short-Term Fee Basis consults. 

Concur 

VA OIG Office of Healthcare Inspections 24 
Bennington, Littleton, Jamestown, Lackawanna, Hagerstown, and Petersburg 

Target date for completion: December 31, 2012 

Policy is currently going through the concurrence process. 

Recommendation 4. We recommended that the Short-Term Fee Basis consults are 

approved for the Littleton CBOC no later than 10 days from the date the consult was 

initiated. 

Concur 

Target date for completion: February 28, 2012 

Having reinforced the requirements for timely consult approval immediately following 

survey, the facility Clinical Executive Board will review 1st Qtr FY12 performance data to 

ensure continued compliance. 

Recommendation 5. We recommended that the Short-Term Fee Basis consults for the 

Bennington and Littleton CBOCs are approved by appropriate leadership or a designee 

in accordance with VHA policy. 

Concur
 

Target date for completion: December 31, 2011
 

The delegation of approval memorandum will be revised to be in compliance with the
 

VHA Policy.
 

Recommendation 6. We recommended that the veterans receive written notification
 

when a Short-Term Fee Basis consult is approved at the Bennington and Littleton
 

CBOCs.
 

Concur
 

Target date for completion: November 30, 2011
 

While WRJ Veterans were receiving written notification of fee service approval, the
 

authorization details were not consistently documented in the medical record. 

Confirmation of authorization and date such authorization is sent to the Veteran will be 

documented directly in the fee consult as part of consult completion. 

Recommendation 7. We recommended that the copies of Short-Term Fee Basis 

reports of the Bennington CBOC patients are filed or scanned into the medical record. 

Concur 

Target date for completion: December 31, 2011 

Challenges surrounding the communication of paper results between VA and non-VA 

providers will be specifically addressed through an in-progress formal collaborative 

VA OIG Office of Healthcare Inspections 25 
Bennington, Littleton, Jamestown, Lackawanna, Hagerstown, and Petersburg 

“Improving Mammography Care” (Collaborative work to date was shared with the 

inspector as part of this survey). A process to ensure timely receipt of short term fee 

care results will be deployed at all CBOCs. Oversight to ensure appropriate and timely 

services will continue to be monitored at the facility Quality Management Board at least 

quarterly. 

Recommendation 8. We recommended that the ordering practitioners, or surrogate 

practitioners, communicate the Short-Term Fee Basis results to the patients within 

14 days from the date made available to the ordering practitioner at the Bennington 

CBOC. 

Concur 

Target date for completion: February 28, 2012 

Having reinforced the requirements for timely notification of study results to all 

appropriate providers immediately following survey, the Clinical Executive Board will 

review 1st Qtr FY12 performance data to ensure continued compliance. 

Recommendation 9. We recommended that managers at the Bennington and Littleton 

CBOCs establish a process to ensure effective oversight of the mammography 

program, as required by VHA policy. 

Concur 

Target date for completion: November 30, 2011 

The VA requirements regarding mammography care have been communicated to the 

appropriate CBOC staff. In addition, the CBOCs are now specifically represented at the 

facility collaborative “Improving Mammography Care”. The CBOC mammography 

process will be specifically included in the oversight monitoring currently conducted 

through the facility Quality Management Board. 

Recommendation 10. We recommended that the managers at the Bennington and 

Littleton CBOCs ensure that all mammogram results are documented using the BIRADS code categories. 

Concur 

Target date for completion: December 31, 2011 

Challenges surrounding the communication of documented results between VA and 

non-VA providers will be specifically addressed through an in-progress formal 

collaborative “Improving Mammography Care” (Collaborative work to date was shared 

with the inspector as part of this survey). A process to ensure timely receipt of short 

term fee care results, to include documented BI-RADS code categories will be deployed 

at all CBOCs. Oversight to ensure appropriate documentation will continue to be 

monitored at the facility Quality Management Board at least quarterly. 

VA OIG Office of Healthcare Inspections 26 
Bennington, Littleton, Jamestown, Lackawanna, Hagerstown, and Petersburg 

Recommendation 11. We recommended that managers establish a process to ensure 

that patients at the Bennington and Littleton CBOCs are notified of mammogram results 

within the allotted timeframe and that notification is documented in the medical record. 

Concur 

Target date for completion: February 28, 2012 

Having reinforced the requirements for timely notification of study results (including 

results obtained for short term fee care) to all appropriate providers immediately 

following survey, the Clinical Executive Board will review 1st Qtr FY12 performance data 

to ensure continued compliance. 

Recommendation 12. We recommended that managers ensure fee basis 

mammography results are received and scanned into CPRS at the Bennington and 

Littleton CBOCs. 

Concur 

Target date for completion: December 31, 2011 

Timely receipt of mammography results and inclusion of those results in the medical 

record will be specifically addressed through an in-progress formal collaborative 

“Improving Mammography Care” (Collaborative work to date was shared with the 

inspector as part of this survey). A process to ensure timely receipt of, and timely 

medical record documentation of short term fee care will be deployed at all CBOCs. 

Oversight to ensure appropriate and timely services will continue to be monitored at the 

facility Quality Management Board at least quarterly. 

Recommendation 13. We recommended that managers at the Bennington and 

Littleton CBOCs establish a process to ensure CPRS mammogram radiology orders are 

entered for all fee-basis mammograms and that all breast imaging and mammography 

results are linked to the appropriate radiology mammogram or breast study order. 

Concur 

Target date for completion: February 28, 2012 

Having communicated this requirement to appropriate staff immediately following 

survey, a process to ensure orders for fee basis mammograms are entered and linked 

to the appropriate radiology order was deployed. The Quality Management Board will 

review performance data covering the 1st Qtr FY12 as part of the oversight of the 

“Improving Mammography Care” collaborative. 

Recommendation 14. We recommended that the parent Facility Director appoints a 

Women’s Health Liaison for the Bennington CBOC and that collaboration occurs with 

the parent facility’s Women Veterans Program Manager. 

VA OIG Office of Healthcare Inspections 27 
Bennington, Littleton, Jamestown, Lackawanna, Hagerstown, and Petersburg 

Concur 

Target date for completion: November 15, 2011 

While a staff member had been identified and was functioning under the scope of this 

responsibility, a formal appointment from the Medical Center Director had not been 

issued. A formal appointment for the Women’s Health Liaison for the Bennington 

CBOC will be issued. 

Recommendation 15. We recommended that the Women’s Health Liaison at the 

Littleton CBOC collaborates with the Women Veterans Program Manager. 

Concur 

Target date for completion: December 31, 2011 

A Women’s Health Liaison for the Littleton CBOC will be identified and officially 

appointed by the Medical Center Director. 

Recommendation 16. We recommended that the policy includes what actions are 

taken when staff cannot demonstrate competency at the Bennington and Littleton 

CBOCs. 

Concur 

Target date for completion: January 31, 2012 

While we have a competency verification policy and process in place, we recognize the 

need to clearly define actions when it is determined that an employee lacks the 

necessary competency. The facility policy will be revised to include specific actions to 

be taken by the supervisor when it has been determined the employee lacks the 

necessary competency for the specific task. 

Recommendation 17. We recommended that core competencies for the ancillary 

clinical staff are defined at the Bennington and Littleton CBOCs. 

Concur 

Target date for completion: December 31, 2011 

Appropriate supervisors will be notified and reminded that identified core competencies 

must be documented through the standardized competency verification checklist 

process maintained at the service level and used for ongoing competency assessment. 

Recommendation 18. We recommended that managers ensure that all patient care 

staff members are trained in BLS with the use of an AED at the Littleton CBOC. 

Concur 

VA OIG Office of Healthcare Inspections 28 
Bennington, Littleton, Jamestown, Lackawanna, Hagerstown, and Petersburg 

Target date for completion: December 31, 2011 

While the facility has a policy outlining the requirements for BLS training, it was recently 

modified to include specific consequences should an employee fail to comply with the 

requirements. Monitoring to ensure compliance for privileged staff will continue to be 

part of the privileging and 24 month reprivileging activity which has oversight provided 

through the Professional Standards Board. In addition, for ancillary and other support 

staff, supervisors will be notified and reminded to include monitoring of these 

requirements as part of the standardized competency verification checklist process. 

Recommendation 19. We recommended that initial and annual competencies are 

assessed and documented at the Bennington CBOC. 

Concur 

Target date for completion: December 31, 2011 

Appropriate supervisors will be notified and reminded that initial and annual 

competencies must be assessed and documented through the standardized 

competency verification checklist process maintained at the service level and used for 

ongoing competency assessment. 

Recommendation 20. We recommended that the Facility Director ensures that the 

PCMM data is accurate in accordance with the VHA directive and specifically includes 

FTEs for contract PCPs and Associate Physicians at the Littleton CBOC. 

Concur 

Target date for completion: January 31, 2012 

The CBOC Coordinator, with the support of the Chief of Primary Care will ensure that 

PCMM data for the contract CBOC is accurate in accordance with VHA Policy and 

includes all contract provider information. 

Recommendation 21. We recommended that the Facility Director and Contracting 

Officer ensure that the contract is modified to clearly define the requirements for 

payment and specifically how the contractor is to be compensated when patients are 

disenrolled. 

Concur 

Target date for completion: July 1, 2012 

The CBOC Coordinator and the Chief Contracting Officer will ensure the contract clearly 

defines all requirements for payment and compensation specifically as it applies to 

patient’s disenrollment. Contract review will be completed and contract modifications 

will be made as necessary. 

VA OIG Office of Healthcare Inspections 29 
Bennington, Littleton, Jamestown, Lackawanna, Hagerstown, and Petersburg 

Recommendation 22. We recommended that the Facility Director and Contracting 

Officer ensure that all contracts include a detailed description of performance measures 

and monitoring procedures that will be utilized to evaluate the contractor’s performance 

and include enforcement provisions if those measures are not met. 

Concur 

Target date for completion: November 30, 2011 

The facility, in conjunction with the Contracting Officer, will initiate a Quality Assurance 

Surveillance Plan (QUASP). This plan will include a detailed description of the 

monitoring procedures used by this facility to ensure contract compliance. Performance 

measure elements will be monitored at least monthly through the facility replicable 

process entitled “1st Friday Performance Review”. This plan will be a living document 

and the facility will review and revise it at least annually. We will coordinate this plan 

with the contractor. 

Recommendation 23. We recommended the Facility Director strengthens the invoice 

validation process to ensure the accuracy of invoiced enrollees, using VA data as the 

basis for determining the payment due to the contractor, which will reduce the risk of 

overpayments. 

Concur 

Target date for completion: January 31, 2012 

The Littleton Contract CBOC COTR, working closely with the Chief Contract Officer, the 

Chief of the Business Office and the facility Compliance Officer will develop and deploy 

an invoice validation process which will include greater than 10 percent of enrollees 

billed each month. In addition, the new system will include an independent process to 

validate patient eligibility to reduce the risk of over overcharges and overpayments. The 

new process will rely primarily on VA data to determine eligibility. 

Recommendation 24. We recommended that the Facility Director determines, with the 

assistance of the Regional Counsel, the extent and collectability of the overpayments on 

the contract. 

Concur 

Target date for completion: January 31, 2012 

The COTR, working closely with the Chief Contract Officer, the Chief of the Business 

Office and the facility Compliance Officer will review and determine any opportunity to 

recover overpayments made related to the Littleton contract CBOC. The COTR will 

seek Regional Counsel support as necessary. 

VA OIG Office of Healthcare Inspections 30 
Bennington, Littleton, Jamestown, Lackawanna, Hagerstown, and Petersburg 

Appendix C

VISN 2 Director Comments

Department of

Veterans Affairs Memorandum

Date: October 17, 2011
 

From: Network Director, VISN 2 (10N2)
 

Subject: CBOC Reviews: Jamestown and Lackawanna, NY
 

To: Director, 54F Healthcare Inspections Division (54F)
 

Director, Management Review Service (VHA 10A4A4) 

Attached is Veterans Affairs Western New York Healthcare System 

(VAWNYHS) response to the draft report of the Jamestown and 

Lackawanna New York CBOCs. I have reviewed the draft report and 

concur with all the findings and recommendations. 

(original signed by:) 

David J. West, FACHE 

VA OIG Office of Healthcare Inspections 31 
Bennington, Littleton, Jamestown, Lackawanna, Hagerstown, and Petersburg 

Appendix D

VA Western New York HCS Director Comments

Department of

Veterans Affairs Memorandum

Date: October 14, 2011
 

From: Director, VA Western New York HCS (528/00)
 

Subject: CBOC Reviews: Jamestown and Lackawanna, NY
 

To: Director, VISN 2 (10N2)
 

1. Attached is Veterans Affairs Western New York Healthcare System 

(VAWNYHS) response to the draft report of the Jamestown and 

Lackawanna New York CBOCs. I have reviewed the draft report and 

concur with all the findings and recommendations. 

2. If you have any questions please contact, Ms. Kathryn Varkonda, 

Performance Manager, at (716) 862-6380. 

(original signed by:) 

Jason C. Petti, MSHA, VHA-CM 

Interim Medical Center Director 

VA OIG Office of Healthcare Inspections 32 
Bennington, Littleton, Jamestown, Lackawanna, Hagerstown, and Petersburg 

Comments to Office of Inspector General’s Report
 

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

to the Office of Inspector General’s report: 

OIG Recommendations

Recommendation 25. We recommended that a plan is developed to define how MH 

emergencies are addressed at the Jamestown and Lackawanna CBOCs. 

Concur 

Target date for completion: October 17, 2011 

A standard operating procedure for mental health emergencies at all VAWNYHS 

CBOCs has been developed, and is in place, and staff have been provided educated on 

its usage. 

Recommendation 26. We recommended that patients receive written notification when 

a Short-Term Fee Basis consult is approved at the Lackawanna CBOC. 

Concur 

Target date for completion: November 18, 2011 

The VISN 2 Non-VA Care Policy and process will be revised by November 18, 2011, to 

include storage within CPRS documentation of the electronic image of the short term 

fee basis approval letter and date it is sent to the Veteran. 

Recommendation 27. We recommended that the ordering practitioners, or surrogate 

practitioners, communicate the Short-Term Fee Basis results to patients within 14 days 

from the date made available to the ordering practitioner at the Lackawanna CBOC. 

Concur 

Target date for completion: October 14, 2011 

VAWNYHS has implemented a process by which practitioners communicate the results 

of Short Term Fee Basis results to patients within 14 days from the date results are 

made available to the ordering provider and documenting their provision in the medical 

record. 

Recommendation 28. We recommended that the Jamestown and Lackawanna 

managers establish a process to ensure patients with normal mammograms are 

provided written notification of results within the allotted timeframe and that notification 

is documented in the medical record. 

Concur 

VA OIG Office of Healthcare Inspections 31 
Bennington, Littleton, Jamestown, Lackawanna, Hagerstown, and Petersburg 

Target date for completion: October 17, 2011 

VAWNYHS has implemented a process by which Veterans with normal mammograms 

at the Jamestown and Lackawanna CBOC will be mailed a copy of their normal 

mammograms within the allotted timeframe and documentation of the mailing of the 

results recorded in the Veteran’s medical record. 

Recommendation 29. We recommended that managers at the Lackawanna CBOC 

establish a process to ensure CPRS mammogram radiology orders are entered for all 

fee-basis mammograms and that all breast imaging and mammography results are 

linked to the appropriate radiology mammogram or breast study order. 

Concur 

Target date for completion: October 17, 2011 

VAWNYHS has implemented a process in which fee basis mammograms will have a 

CPRS order to enable mammogram results to be linked to the study order. The 

VAWNYHS Radiology manager has trained all CBOC staff on the process and will 

monitor linkage of study results to orders on a quarterly basis. 

Recommendation 30. We recommended that FPPEs at the Jamestown and 

Lackawanna CBOCs have clearly defined timeframes and that results are reported to 

the ECMS, documented in the ECMS minutes, and placed in the provider profiles. 

Concur 

Target date for completion: November 12, 2011 

VAWNYHS has in place a process by which all provider FPPE timeframes and results 

are reported to ECMS, documented in the ECMS minutes, and placed in provider 

profiles. The Jamestown and Lackawanna CBOC providers FPPEs audited were 

conducted prior to VAWNYHS implementing this process. The Jamestown and 

Lackawanna CBOC provider FPPEs inclusive of required timeframes will be reported to 

the November 2011 ECMS, documented in the ECMS minutes, and placed in the 

provider profiles. 

Recommendation 31. We recommended that all LCSWs at the Lackawanna CBOC 

have scopes of practice that are facility, service, and provider-specific. 

Concur 

Target date for completion: January 30, 2012 

All VAWNYHS CBOC LCSW are in the process of having scopes of practice defined 

that are facility, service, and provider specific via the Credentialing and Privileging 

Process (C & P). Fifteen VAWNYHS CBOC LCSW have already had scopes of 

VA OIG Office of Healthcare Inspections 32 
Bennington, Littleton, Jamestown, Lackawanna, Hagerstown, and Petersburg 

practice defined via the facility C & P process and the remaining CBOC LCSWs will be 

have scopes of practice defined via C & P by January 30, 2012. 

Recommendation 32. We recommended that the Lackawanna CBOC manager 

ensures that all patient care staff members are trained and assessed for BLS and 

phlebotomy on an annual basis as required by local policy. 

Concur 

Target date for completion: December 1, 2011 

All Lackawanna CBOC patient care staff will be trained and assessed for BLS by an 

outside contractor and by VAWNYHS laboratory staff for phlebotomy. Both the outside 

contractor and VAWNYHS laboratory staff have clinical expertise in their respective 

areas. The VAWNYHS CBOC Contracting Officer Technical Representative (COTR) 

will monitor the completion of BLS and phlebotomy training of Lackawanna CBOC staff 

on an annual basis. 

Recommendation 33. We recommended that clinical competencies at the 

Lackawanna CBOC are assessed by an individual who has the appropriate clinical 

background and a current assessment of clinical skills. 

Concur 

Target date for completion: October 14, 2011 

All clinical competencies at the Lackawanna CBOC have been conducted and assessed 

by an individual who has the appropriate clinical background to assess the competency 

of the staff member. The VAWNYHS COTR will review staff competencies on an 

annual basis to ensure that they were conducted by an individual with the appropriate 

clinical background. 

Recommendation 34. We recommended that the Lackawanna CBOC allocates 

handicap parking spaces as required by ADA. 

Concur 

Target date for completion: February 28, 2012 

The Contracting Officer has notified the CBOC vendor via official letter that a clearly 

labeled, dedicated handicapped space adjacent to the building is required for the 

CBOC. A City of Buffalo variance will be required to enable the vendor to be in 

compliance with the changes outlined by the Contracting Officer. 

Recommendation 35. We recommended that the identified fire and life safety issues 

at the Lackawanna CBOC are corrected. 

Concur 

VA OIG Office of Healthcare Inspections 33 
Bennington, Littleton, Jamestown, Lackawanna, Hagerstown, and Petersburg 

Target date for completion: September 30, 2011 

The identified fire and life safety issues at the Lackawanna CBOC have been corrected 

by the vendor. The VAWNYHS Life Safety Specialist physically verified and 

documented the correction of the fire and life safety issues at the Lackawanna CBOC. 

Recommendation 36. We recommended that the Facility Director ensures that the 

invoice validation process includes a review of the accuracy of contracted capitated 

rates presented on the invoices for the Jamestown and Lackawanna CBOCs. 

Concur 

Target date for completion: September 30, 2011 

The VAWNYHS CBOC COTR will review CBOC invoices on a monthly basis to ensure 

that invoices are being billed according to the defined criteria for calculation listed within 

the contract. 

Recommendation 37. We recommended that the Contracting Officer ensures the 

contract clearly states the requirements for payment and that all actionable terms are 

clearly defined for the Jamestown and Lackawanna CBOCs. 

Concur 

Target date for completion: November 30, 2012 

The Contracting Officer will modify the Jamestown and Lackawanna CBOC contracts to 

include language that clarifies requirements for payment and defines actionable terms. 

VA OIG Office of Healthcare Inspections 34 
Bennington, Littleton, Jamestown, Lackawanna, Hagerstown, and Petersburg 

Appendix E

VISN 5 Director Comments

Department of

Veterans Affairs	 Memorandum

Date: October 19, 2011 

From: Director, VISN 5 (10N5) 

Subject: CBOC Reviews: Hagerstown, MD and Petersburg, WV

To: Director, 54F Healthcare Inspections Division (54F) 

Director, Management Review Service (VHA 10A4A4) 

1.	 We appreciate the opportunity for this review as a continuing process 

to improve the care to our Veterans. The Office of Inspector General 

Community Based Outpatient Clinic Team was professional and 

consultative during the review. 

2.	 I have reviewed the comments provided by the Medical Center 

Director, Martinsburg VA Medical Center and concur with the 

responses and proposed action plans to the recommendations outlined 

in the report. 

3.	 If further information is required, please contact V. Denise O’Dell, RN, 

MSA, CPHQ, Chief Quality Management, Martinsburg VA Medical 

Center, at (304) 263-0811, extension 4035. 

(original signed by Guy Richardson, Deputy Network Director for:) 

Fernando O. Rivera, Network Director 

VA OIG Office of Healthcare Inspections 35 
Bennington, Littleton, Jamestown, Lackawanna, Hagerstown, and Petersburg 

Appendix F

Martinsburg VAMC Director Comments

Department of

Veterans Affairs Memorandum

Date: October 19, 2011 

From: Director, Martinsburg VAMC (613/00) 

Subject: CBOC Reviews: Hagerstown, MD and Petersburg, WV

To: Director, VISN 5 (10N5) 

1.	 Thank you for allowing me to respond to this Community Based 

Outpatient Clinic (CBOC) Review of Hagerstown, MD and Petersburg, 

WV facilities. We found the review educational and helpful. We 

appreciate the professionalism demonstrated by the OIG CBOC Team. 

2.	 Attached please find the Martinsburg responses and relevant action for 

the 22 recommendations from the Office of the Inspector General 

Community Based Outpatient Clinic review conducted 8/29-31, 2011. 

3.	 If you have any questions regarding this report please contact V. 

Denise O’Dell, RN, MSA, CPHQ, Chief Quality Management, 

Martinsburg VAMC, at (304) 263-0811, extension 4035. 

(original signed by:) 

Ann R. Brown, FACHE, Medical Center Director 

VA OIG Office of Healthcare Inspections 36 
Bennington, Littleton, Jamestown, Lackawanna, Hagerstown, and Petersburg 

Comments to Office of Inspector General’s Report
 

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

to the Office of Inspector General’s report: 

OIG Recommendations

Recommendation 38. We recommended that the facility develops a local policy for 

Short-Term Fee Basis consults. 

Concur 

Target date for completion: 12/15/2011 

A local policy for Short-Term Fee Basis consults will be developed by Medical 

Administrative Service and approved by the Medical Center Director by December 15, 

2011. 

Recommendation 39. We recommended that the providers at the Hagerstown CBOC 

document a justification for the use of Short-Term Fee Basis care in the medical record. 

Concur 

Target date for completion: 12/15/2011 

A local policy for Short-Term Fee Basis Consults will be developed by Medical 

Administrative and approved by the Medical Center Director by December 15, 2011. 

The policy will emphasize the requirement of the clinician to justify the decision to seek 

non-VA care on the consult. This will be made a field in the consult template for 

ordering. 

Recommendation 40. We recommended that Short-Term Fee Basis consults are 

approved at the Hagerstown and Petersburg CBOCs no later than10 days from the date 

the consult was initiated. 

Concur 

Target date for completion: 12/15/2011 

The Martinsburg VAMC procedure for approval of Short-Term Fee Basis consults is to 

have approval within 10 days. The issue was in how this approval is documented 

(during the time of review this was not electronic) and to have it as part of the electronic 

consult template for reviewing in CPRS. This procedure will be outlined as part of the 

local policy to be developed and approved by December 15, 2011. 

VA OIG Office of Healthcare Inspections 37 
Bennington, Littleton, Jamestown, Lackawanna, Hagerstown, and Petersburg 

Recommendation 41. We recommended that the Short-Term Fee Basis consults at 

the Hagerstown and Petersburg CBOCs are approved by appropriate leadership or a 

designee in accordance with VHA policy. 

Concur 

Target date for completion: 12/15/2011 

Short-Term Fee Basis consults at Martinsburg VAMC are approved by the appropriate 

leadership or designee in accordance with VHA directives; however, the process for 

designees (during absences, personnel in an acting capacity) was not clearly articulated 

as part of this process. The VAMC will enhance the Short-Term Fee Basis Consults 

policy to specifically include that designee/acting personnel can approve short-term fee 

basis consults. Medical Administrative Service will be notified (by Chief of Staff) when a 

designee/acting personnel has approving capacity. This will be reflected in the Short 

Term Fee Basis Consults policy. 

Recommendation 42. We recommended that the patients receive written notification 

when a Short-Term Fee Basis consult is approved at the Hagerstown and Petersburg 

CBOCs. 

Concur 

Target date for completion: 12/15/2011 

Although this was part of the process for Short-Term Fee Basis patients, it was not 

articulated in local policy or retrievable in the medical record documentation. This will 

be strengthened and included in the Short Term Fee Basis Consult policy by 

12/15/2011. Providers will be notified of this strengthened practice by the Chief of Staff 

and designated Clinical Service Chiefs, as appropriate by 12/15/2011. 

Recommendation 43. We recommended that the copies of Short-Term Fee Basis 

reports of Hagerstown CBOC patients are filed or scanned into the medical record. 

Concur 

Target date for completion: 12/15/2011 

A local policy for Short-Term Fee Basis consults will be developed by Medical 

Administrative Service and approved by the Medical Center Director by December 15, 

2011. The policy will request that non-VA care providers submit appropriate medical 

documentation with the claims form to the Fee Basis office. Fee Basis staff will be 

responsible for scanning the documents into DocManager and following up with non-VA 

care providers if documentation is lacking by 12/15/2011. 

Recommendation 44. We recommended that the ordering providers, or surrogate 

practitioners, at the Hagerstown CBOC review Short-Term Fee Basis reports within 

14 days from the date on which the results are available. 

VA OIG Office of Healthcare Inspections 38 
Bennington, Littleton, Jamestown, Lackawanna, Hagerstown, and Petersburg 

Concur 

Target date for completion: 12/15/2011 

Per our policy on Reporting Testing Results, the providers will be responsible for 

documenting review of Short-Term Fee Basis results into CPRS. Providers will be 

responsible for generating a test results letter to the patient upon receipt of View Alert 

that the exam results are in CPRS. This letter must be generated within 14 days of the 

viewable results being in CPRS. Providers will be notified of this strengthened practice 

by the Chief of Staff and designated Clinical Service Chiefs, as appropriate by 

12/15/2011. 

Recommendation 45. We recommended that the ordering providers, or surrogate 

practitioners, at the Hagerstown CBOC communicate the Short-Term Fee Basis results 

to the patient within 14 days from the date the results are made available to the ordering 

provider. 

Concur 

Target date for completion: 12/15/2011 

Per our policy on Reporting Testing Results, the providers will be responsible for 

generating a test results letter to the patient upon receipt of View Alert that the exam 

results are in CPRS. This letter must be generated within 14 days from the date the 

results are made available to the ordering provider. Providers will be notified of this 

strengthened practice by the Chief of Staff and designated Clinical Service Chiefs, as 

appropriate by 12/15/2011. 

Recommendation 46. We recommended that mammogram results at the Hagerstown 

CBOC are documented using BI-RADS categories. 

Concur 

Target date for completion: 11/1/2011 

The standard operating procedure for the mammogram process was amended in the 4th 

QTR of FY 2011 with education and guidelines to our mammography imagining 

contractors. This includes entry of the mammography results with documented BIRADS categories to be included into the report. This information is then forwarded to 

Martinsburg for scanning into CPRS. The Women Health Clinic also has begun tracking 

(October 1, 2011) all mammograms ordered by our facility for completeness with BIRADS category. 

Recommendation 47. We recommended that managers at the Hagerstown and 

Petersburg CBOCs establish and monitor a process to ensure timely notification of 

normal mammography results to patients. 

Concur 

VA OIG Office of Healthcare Inspections 39 
Bennington, Littleton, Jamestown, Lackawanna, Hagerstown, and Petersburg 

Target date for completion: 12/15/2011 

Per our policy on Reporting Testing Results, the providers will be responsible for 

generating a test results letter to the patient upon receipt of View Alert that the exam 

results are in CPRS. This letter must be generated within 14 days from the date the 

results are made available to the ordering provider. Providers will be notified of this 

strengthened practice by the Chief of Staff and designated Clinical Service Chiefs, as 

appropriate by 12/15/2011. 

Recommendation 48. We recommended that the PSB grants privileges consistent 

with the services provided at the Hagerstown CBOC. 

Concur 

Target date for completion: 11/30/2011 

The provider in question at the Hagerstown CBOC has been reviewed by Credentialing 

and Privileging staff and the appropriate changes in scope have been made and will be 

taken to PSB in November 2011. 

Recommendation 49. We recommended that FPPEs are initiated for all licensed 

independent practitioners who have been newly hired at the Hagerstown CBOC. 

Concur 

Target date for completion: 11/1/2011 

The Credentialing and Privileging process includes the initiation of FPPE’s on all new 

hires at Martinsburg VAMC CBOCs. The Credentialing and Privileging staff will ensure 

that all FPPE’s will be initiated at time of appointment to medical staff. A review of all 

new hires will be done on a quarterly basis by Credentialing and Privileging staff to 

ensure compliance. 

Recommendation 50. We recommended that non- licensed independent practitioners’ 

scopes of practice accurately reflect their specialty practices at the Hagerstown CBOC. 

Concur 

Target date for completion: 11/30/2011 

The employee in question at the Hagerstown CBOC has been reviewed by 

Credentialing and Privileging staff and the appropriate changes in scope have been 

made and will be taken to PSB in November 2011. 

Recommendation 51. We recommended that the entrance door at the Petersburg 

CBOC is ADA accessible. 

Concur 

VA OIG Office of Healthcare Inspections 40 
Bennington, Littleton, Jamestown, Lackawanna, Hagerstown, and Petersburg 

Target date for completion: 1/31/2012 

The entrance door handles meeting ADA requirements have been ordered and will be in 

place by 1/31/2012. Facility Management Service is working with Contracting Service 

to address these concerns. The project number for this correction is #613-12-303. 

Recommendation 52. We recommended that the security of patient PII is maintained 

at the Hagerstown and Petersburg CBOCs. 

Concur 

Target date for completion: 12/31/2011 

Plastic breakaway locks will be purchased to secure transfer containers used to 

transport laboratory specimens from CBOCs to the parent facility by 12/31/2011. 

Recommendation 53. We recommended that auditory privacy is maintained during the 

check-in process at the Hagerstown CBOC. 

Concur 

Target date for completion: 12/1/2011 

To ensure auditory privacy of PII at both Hagerstown and Petersburg CBOC’s, signage 

has been posted at the check-in areas requesting patients to stand behind the 

stanchions while waiting to be called to the counter for assistance. All CBOC staff will 

be trained and educated to remind patients to respect privacy by providing space and 

distance. Staff will be instructed to speak to patients being served at the check-in 

counter in a volume appropriate to personal conversations. This training will be done 

by CBOC coordinators by 12/1/2011. This will also be added to CBOC Orientation 

checklist for new employees by 12/1/2011. 

Recommendation 54. We recommended that the Chief of OI&T evaluates the use of 

the IT closet at the Petersburg CBOC and implements appropriate measures according 

to VA policy. 

Concur 

Target date for completion: 1/31/2012 

Chief of OI&T will evaluate the use of the IT closet at the Petersburg CBOC and 

recommend any necessary changes to made in the contract for that location. 

Recommendation 55. We recommended that floor model sharps containers are 

secured at the Hagerstown CBOC. 

Concur 

Target date for completion: 10/21/2011 

VA OIG Office of Healthcare Inspections 41 
Bennington, Littleton, Jamestown, Lackawanna, Hagerstown, and Petersburg 

Floor model sharps containers at the Hagerstown CBOC will be secured no later than 

10/21/2011. Platforms have been ordered by our Acquisition and Materials 

Management Service and will be delivered to clinic for install during week of October 17, 

2011. 

Recommendation 56. We recommended that managers ensure that an AED is 

available at the Petersburg CBOC. 

Concur 

Target date for completion: 10/31/2011 

AED box has been installed on a wall of the clinic at Petersburg CBOC (September 30, 

2011). The CBOC received the AED on 10/6/2011. 

Recommendation 57. We recommended that the Facility Director and Contracting 

Officer consider utilizing a 12-month vesting criteria for future contracts to ensure a 

more effective use of VHA healthcare resources. 

Concur 

Target date for completion: 1/1/2012 

Consideration will be given for establishing a 12-month vesting criteria for future 

contracts starting 1/1/2012. 

Recommendation 58. We recommended that the Facility Director and Contracting 

Officer ensure pricing for all ancillary charges are identified in the contract. 

Concur 

Target date for completion: 3/31/2012 

The existing Petersburg contract is based upon a fixed rate and will expire 9/30/13 

(option year 4). A multidisciplinary team will be formed to develop the statement of work 

for the future contract and consideration will be given to identify all necessary services 

included within the scope as well as contractual terms that address ancillary charges. 

Recommendation 59. We recommended that the Contracting Officer ensures 

competition in the solicitation process by giving all bidders the opportunity to bid on the 

same requirements, specifically when changes are made after the solicitation has 

closed. 

Concur 

Target date for completion: 1/31/2012 

Future necessary changes to the existing contract will consider competitive quotes of 

suppliers and subcontractors, as available. 

VA OIG Office of Healthcare Inspections 42 
Bennington, Littleton, Jamestown, Lackawanna, Hagerstown, and Petersburg 

Appendix G

OIG Contact and Staff Acknowledgments

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

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

Contributors Marisa Casado, RN, MSA, Project Manager 

Gail Bozzelli, RN 

Elizabeth Burns, MSSW 

Shirley Carlile, BA 

Lin Clegg, PhD 

Marnette Dhooghe, MS 

Nathan Fong, CPA 

Zhana Johnson, CPA 

Sandra Khan, RN 

Anthony M. Leigh, CPA 

Sarah Lutter, RN, JD 

Karen Moore, RN 

Sami O’Neill, MA 

Jennifer Reed, RN 

Noel Rees, MPA 

Thomas J. Seluzicki, CPA 

Marilyn Stones, BS 

VA OIG Office of Healthcare Inspections 43 
Bennington, Littleton, Jamestown, Lackawanna, Hagerstown, and Petersburg 

Appendix H

Report Distribution

VA Distribution

Office of the Secretary
 

Veterans Health Administration
 

Assistant Secretaries
 

General Counsel
 

Director, VISN 1 (10N1)
 

Director, White River Junction VAMC (405/00)
 

Director, VISN 2 (10N2)
 

Director, VA Western New York HCS (528/00)
 

Director, VISN 5 (10N5)
 

Director, Martinsburg VAMC (613/00)
 

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: Kelly Avotte, Benjamin L. Cardin, Kirsten E. Gillibrand, Patrick J. Leahy, 

Joe Manchin III, Barbara A. Mikulski, John D. Rockefeller IV, Bernard Sanders, 

Charles E. Schumer, Jeanne Shaheen 

U.S. House of Representatives: Roscoe G. Bartlett, Charles F. Bass, Brian Higgins, 

David B. McKinley, Peter Welch 

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

VA OIG Office of Healthcare Inspections 44