Department of Veterans Affairs

Office of Inspector General

Office of Healthcare Inspections
 

Report No.11-00844-220

Community Based Outpatient
 

Clinic Reviews
 

Springfield, MA
 

Morehead City and Raleigh, NC

Clarksville and Cookeville, TN

Wichita Falls, TX

Klamath Falls, OR

July 6, 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 to 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)
Springfield, Morehead City, Raleigh, Clarksville, Cookeville, Wichita Falls, and Klamath Falls 

Glossary

A1c glycated hemoglobin 

C&P credentialing and privileging 

CBOC community based outpatient clinic 

COTR Contracting Officer’s Technical Representative 

CPRS Computerized Patient Record System 

DM Diabetes Mellitus 

EKG electrocardiogram 

EOC environment of care 

FY fiscal year 

FTE full-time employee equivalents 

HCS Health Care System 

IC infection control 

LCSW Licensed Clinical Social Worker 

LPN Licensed Practical Nurse 

MH mental health 

MST military sexual trauma 

NP nurse practitioner 

OIG Office of Inspector General 

OPPE Ongoing Professional Practice Evaluation 

PA physician assistant 

PI performance improvement 

PCMM Primary Care Management Module 

PCP primary care provider 

PSB Professional Standards Board 

PTSD Post-Traumatic Stress Disorder 

Qtr quarter 

RN registered nurse 

SOP standard operating procedure 

SORCC Southern Oregon Rehabilitation Center and Clinics 

VAMC VA Medical Center 

VHA Veterans Health Administration 

VISN Veterans Integrated Service Network 

VSSC VHA Support Service Center 

VA OIG Office of Healthcare Inspections 
Springfield, Morehead City, Raleigh, Clarksville, Cookeville, Wichita Falls, and Klamath Falls 

Table of Contents
 

Page
 

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

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

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

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

Results and Recommendations................................................................................ 3
 

VISN 1, Northampton VAMC – Springfield.............................................................. 3
 

VISN 6, Durham VAMC – Morehead City and Raleigh ........................................... 8
 

VISN 9, Tennessee Valley HCS – Clarksville and Cookeville................................. 12
 

VISN 16, Oklahoma City VAMC – Wichita Falls...................................................... 18
 

VISN 20, SORCC – Klamath Falls.......................................................................... 25
 

Appendixes

A. VISN 1 Director Comments ............................................................................... 29
 

B. Northampton Director Comments...................................................................... 30
 

C. VISN 6 Director Comments ............................................................................... 32
 

D. Durham VAMC Director Comments .................................................................. 33
 

E. VISN 9 Director Comments ............................................................................... 34
 

F. Tennessee Valley HCS Director Comments...................................................... 35
 

G. VISN 16 Director Comments ............................................................................. 38
 

H. Oklahoma City VAMC Director Comments........................................................ 39
 

I. VISN 20 Director Comments ............................................................................. 42
 

J. SORCC Acting Director Comments................................................................... 43
 

K. OIG Contact and Staff Acknowledgments ......................................................... 45
 

L. Report Distribution............................................................................................. 46
 

VA OIG Office of Healthcare Inspections 
Springfield, Morehead City, Raleigh, Clarksville, Cookeville, Wichita Falls, and Klamath Falls 

Executive Summary
 

Purpose: We conducted the review of seven CBOCs during the week of 

March 7, 2011. CBOCs were reviewed in VISN 1 at Springfield, MA; in VISN 6 at 

Morehead City and Raleigh, NC; in VISN 9 at Clarksville and Cookeville, TN; in VISN 16 

at Wichita Falls, TX; and, in VISN 20 at Klamath Falls, OR. The parent facilities of 

these CBOCs are Northampton VAMC, Durham VAMC, Tennessee Valley HCS, 

Oklahoma City VAMC, and Southern Oregon Rehabilitation Center and Clinics, 

respectively. The purpose was to evaluate selected activities, assessing whether the 

CBOCs are operated in a manner that provide veterans with consistent, safe, highquality health care. 

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

respective CBOC manager, should take appropriate actions to: 

Northampton VAMC 

	 Ensure that the C&P Committee grants privileges appropriate for the services 

provided at the Springfield CBOC. 

	 Ensure that the C&P Committee documents adequate discussion of providers’ PI 

data prior to reprivileging at the Springfield CBOC. 

	 Implement a plan to improve communication of normal test results to patients and 

monitor compliance at the Springfield CBOC. 

Durham VAMC 

We made no recommendations. 

Tennessee Valley HCS 

	 Ensure that contract pre-award process is performed with adequate time to ensure 

award before expiration of current contract. 

	 Ensure that key contract terminology is clearly defined. 

	 Ensure that staff providing oversight of contracted medical care have a clear 

understanding of the performance and payment provisions in the contract. 

	 Reduce the number of patients assigned to more than one PCP in accordance with 

the VHA guidance. 

Oklahoma City VAMC 

	 Ensure that adequate competency data is maintained in all providers’ profiles at the 

Wichita Falls CBOC. 

VA OIG Office of Healthcare Inspections i 
Springfield, Morehead City, Raleigh, Clarksville, Cookeville, Wichita Falls, and Klamath Falls 

	 Require that the ordering provider documents patient notification and follow-up 

actions in response to critical results at the Wichita Falls CBOC. 

	 Require that normal test results are consistently communicated to patients within the 

specified timeframe at the Wichita Falls CBOC. 

	 Ensure that reports of radiology exams and laboratory tests are consistently entered 

into CPRS at the Wichita Falls CBOC. 

	 Ensure that contract oversight includes the monitoring of performance measures and 

enforcement of incentives and penalties when applicable, as required per the 

contract. 

	 Ensure that contract requirements and modifications, including extensions, are 

appropriate and consistent with the federal acquisition requirements. 

	 Ensure the accuracy of reported PCMM data is in accordance with the VA 

Handbook. 

SORCC 

	 Ensure that measurable performance data is maintained in all provider profiles to 

support physician reprivileging at the Klamath Falls CBOC. 

	 Ensure that normal test results are consistently communicated to patients within the 

specified timeframe at the Klamath Falls CBOC. 

Comments

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

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

pages 29–44 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 ii 
Springfield, Morehead City, Raleigh, Clarksville, Cookeville, Wichita Falls, and Klamath Falls 

Part I. Objectives and Scope

Objectives. The purposes of this review are to: 

 Determine whether CBOC performance measure scores are comparable to the 

parent VAMC or HCS outpatient clinics. 

 Determine whether CBOC providers are appropriately credentialed and privileged in 

accordance to VHA Handbook 1100.19.1 

 Determine whether appropriate notification and follow-up action are documented in 

the medical record when critical laboratory test results are generated. 

 Determine the extent patients are notified of normal laboratory test results. 

 Determine whether CBOCs are in compliance with standards of operations 

according to VHA Handbook 1006.12 in the areas of environmental safety and 

emergency planning. 

 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 Handbook 1101.02.3 

Scope. The topics discussed in this report include: 

 Quality of Care Measures 

 C&P 

 Management of Laboratory Results 

 EOC and Emergency Management 

 CBOC Contracts 

We reviewed CBOC policies, performance documents, provider C&P files, and nurses’ 

personnel records. For each CBOC, we evaluated the quality of care measures by 

reviewing 50 randomly selected patients with a diagnosis of DM and 30 female patients 

between the ages of 52 and 69 who had mammograms, unless fewer patients were 

available. We reviewed the medical records of these selected patients to determine 

compliance with VHA performance measures. 

We also reviewed medical records for 10 patients who had critical laboratory results and 

1 VHA Handbook 1100.19, Credentialing and Privileging, November 14, 2008.
 2 VHA Handbook 1006.1, Planning and Activating Community-Based Outpatient Clinics, May 19, 2004.
 3 VHA Handbook 1101.02, Primary Care Management Module (PCMM), April 21, 2009.
 

VA OIG Office of Healthcare Inspections 1 
Springfield, Morehead City, Raleigh, Clarksville, Cookeville, Wichita Falls, and Klamath Falls 

10 patients with normal laboratory results or fewer if 10 were not available. We will use 

the term critical value or result as defined in VHA Directive 2009-019.4 A critical test 

result is defined as those values or interpretations that, if left untreated, could be life 

threatening or place the patient at serious risk. All emergent test results and some 

abnormal test results constitute critical values or results. Although not defined in the 

directive, we will use the term normal results to describe test or procedure results that 

are neither emergent nor abnormal, or results that are within or marginally outside the 

expected or therapeutic range. 

We conducted EOC inspections to determine the CBOCs’ cleanliness and condition of 

the patient care areas, condition of equipment, adherence to clinical standards for IC 

and patient safety, and compliance with patient data security requirements. We 

evaluated whether the CBOCs had a local policy/guideline defining how health 

emergencies, including MH emergencies, are handled. 

We evaluated whether the Cookeville and Wichita Falls CBOC contracts provided 

guidelines that the contractor needed to follow in order to address quality of care issues. 

We also verified that the number of enrollees or visits reported was supported by 

collaborating documentation. 

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

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

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

VA OIG Office of Healthcare Inspections 2 
Springfield, Morehead City, Raleigh, Clarksville, Cookeville, Wichita Falls, and Klamath Falls 

Part II. Results and Recommendations

A. VISN 1, Northampton VAMC – Springfield

CBOC Characteristics

Table 1 shows the characteristics of the Springfield CBOC. 

CBOC Characteristics Springfield

Type of CBOC VA Staffed 

Number of Uniques, FY 2010 6,119 

Number of Visits, FY 2010 42,274 

CBOC Size5 Large 

Locality Urban 

FTE Provider(s) 4.98 

Type Providers Assigned Internal Medicine Physician 

PCP 

PA 

NP 

Psychiatrists 

Psychologists 

LCSW 

Clinical Nurse Specialist 

Ancillary Staff Assigned RN 

LPN 

Pharmacist 

Social Worker 

Laboratory Technician 

Health Technician/Medical Assistant 

Type of MH Providers Psychiatrists 

Psychologist 

NP/Clinical Nurse Specialist 

LCSW 

Addiction Counselors 

Provides MH Services Yes 

 Evening Hours No 

 Weekends No 

 Plan for Emergencies Outside of Business Hours No 

 Provided Onsite General MH services 

Substance Use Disorder 

PTSD 

MST 

Homelessness 

 Referrals Another VA facility 

Fee-Basis or contract 

 Tele-Mental Health Yes 

5 Based on the number of unique patients seen as defined by the VHA Handbook 1160.01. 

VA OIG Office of Healthcare Inspections 3 
Springfield, Morehead City, Raleigh, Clarksville, Cookeville, Wichita Falls, and Klamath Falls 

CBOC Characteristics (cont’d) Springfield

Specialty Care Services Onsite Yes 

 Type Neurology 

Women’s Health 

Urology 

 Referrals Another VA facility 

Fee-Basis or contract 

Ancillary Services Provided Onsite Laboratory 

Onsite Pharmacy 

Physical Medicine 

EKG 

Miles to Parent Facility 23 

Table 1: CBOC Characteristics

Quality of Care Measures6

DM 

Diabetes is the leading cause of new cases of blindness among adults age 20−74 and 

diabetic retinopathy causes 12,000 to 24,000 new cases of blindness each year. 

Detection and treatment of diabetic eye disease with laser therapy can reduce the 

development of severe vision loss by an estimated 50−60 percent. Table 2 displays the 

parent facility’s and the Springfield CBOC’s compliance in screening for retinopathy. 

Measure 

Meets 

Target Facility 

Qtr 3 

Numerator 

Qtr 3 

Denominator 

Qtr 3 

(%) 

DM – Retinal Eye 

Exam 

70% 631 Northampton VAMC 41 51 81 

631BY Springfield CBOC 36 46 78 

Table 2. Retinal Exam, FY 2010

A1c is a blood test that measures average blood glucose (sugar) levels. Research 

studies in the United States and abroad have found that improved glycemic control 

benefits people with either type I or type II diabetes. In general, for every 1 percent 

reduction in A1c, the relative risk of developing microvascular diabetic complications 

(eye, kidney, and nerve disease) is reduced by 40 percent. The American Diabetes 

Association recommends an A1c of less than 7 percent. Patients with poorly controlled 

diabetes (A1c greater than 9 percent) are at higher risk of developing diabetic 

complications. Measuring A1c assesses the effectiveness of therapy. For this indicator, 

low scores indicate better compliance. Table 3 displays the scores of the parent facility 

and the Springfield CBOC. 

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. It corrects for the unequal number of available cases within each 

organizational level (i.e., CBOC, facility) and protects against the calculation of biased or inaccurate scores. 

Weighting can alter the raw measure score (numerator/denominator). Raw scores can go up or down depending on 

which cases pass or fail a measure. Sometimes the adjustment can be quite significant. 

VA OIG Office of Healthcare Inspections 4 

6 
Springfield, Morehead City, Raleigh, Clarksville, Cookeville, Wichita Falls, and Klamath Falls 

Meets 

Target 

Qtr 3 

Numerator 

Qtr 3 

Denominator

Qtr 3 

Measure Facility (%) 

DM –A1c > 9 or not 16% 631 Northampton VAMC 10 51 23 

done in past year 

631BY Springfield CBOC 7 46 15 

Table 3. A1c Testing, FY 2010

Women’s Health 

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

with approximately 207,000 new cases reported each year.7 It is most common in 

women over 50. Women whose breast cancer is detected early have more treatment 

choices and better chances for survival. Screening by mammography (an x-ray of the 

breast) has been shown to reduce mortality by 20–30 percent among women 40 and 

older. Comparison of the Springfield CBOC to the parent facility’s breast cancer 

screening is listed in Table 4. 

Measure 

Meets 

Target Facility 

Qtr 3 

Numerator 

Qtr 3 

Denominator 

Qtr 3 

(%) 

Mammography, 

50-69 years old 

77% 631 Northampton VAMC 18 21 86 

631BY Springfield CBOC 27 30 90 

Table 4. Women’s Health, FY 2010

C&P

We reviewed the C&P files of five providers and the personnel folders of four nurses at 

the Springfield CBOC. All providers possessed full, active, current, and unrestricted 

licenses, and all required credentials were primary source verified. All nurses’ license 

and education requirements were verified and documented. Service-specific criteria for 

OPPE had been developed and approved. We found sufficient performance data to 

meet current requirements. However, we found the following areas that required 

improvement. 

Clinical Privileges 

The C&P Committee8 granted providers clinical privileges for procedures, including 

minor suturing and wound debridement, which were not performed at the Springfield 

CBOC. VHA policy requires that facility managers grant clinical privileges that are 

facility specific, setting specific, and provider specific.9 

7 American Cancer Society, Cancer Facts & Figures 2009. 

8 The facility’s C&P Committee performs the same function as a PSB. 

9 VHA Handbook 1100.19. 

VA OIG Office of Healthcare Inspections 5 
Springfield, Morehead City, Raleigh, Clarksville, Cookeville, Wichita Falls, and Klamath Falls 

C&P Committee Minutes 

The C&P Committee meeting minutes did not reflect adequate discussion for any of the 

five providers’ performance data prior to reprivileging. VHA policy requires that the C&P 

Committee consider professional performance data prior to reprivileging and that the 

minutes reflect the committee’s discussions.10 

Recommendation 1. We recommended that the C&P Committee grants privileges 

appropriate for the services provided at the Springfield CBOC. 

Recommendation 2. We recommended that the C&P Committee documents adequate 

discussion of providers’ PI data prior to reprivileging at the Springfield CBOC. 

Management of Laboratory Results

VHA Directive 2009-019 requires critical test results to be communicated to the ordering 

provider or surrogate provider within a timeframe that allows for prompt attention and 

appropriate clinical action to be taken. VHA also requires that the ordering provider 

communicate test results to patients so that they may participate in health care 

decisions. Each parent facility is required to develop a written policy for communicating 

test results to providers and documenting communications in the medical record, to 

include a system for surrogate providers to receive results when the ordering provider is 

not available. In addition, ordering providers are required to communicate outpatient 

test results (those not requiring immediate attention) to patients no later than 

14 calendar days from the date on which the results are available to the ordering 

provider. 

We reviewed the parent facility’s policies and procedures and the medical records of 

patients who had tests resulting in critical values and normal values. We found the 

following, with one process that needed improvement. 

Critical Laboratory Results 

We found that the Springfield CBOC had effective processes in place to communicate 

critical laboratory test results to ordering providers and patients. We reviewed the 

medical records of 10 patients who had critical laboratory results and found that 

9 (90 percent) records contained documented evidence of patient notification and 

follow-up actions. 

Normal Laboratory Results 

We found that the medical records of 10 patients at the Springfield CBOC who had 

normal test results. We found documentation that the providers communicated the 

normal results to only one patient within 14 calendar days from the date the results were 

available to the ordering provider. 

10 VHA Handbook 1100.19. 

VA OIG Office of Healthcare Inspections 6 
Springfield, Morehead City, Raleigh, Clarksville, Cookeville, Wichita Falls, and Klamath Falls 

Recommendation 3. We recommended that managers implement a plan to improve 

communication of normal test results to patients and monitor compliance at the 

Springfield CBOC. 

Environment and Emergency Management

EOC 

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

general maintenance. The CBOC met most standards, and the environment was 

generally clean and safe. We found that the IC program monitored data and 

appropriately reported that data to relevant committees. Safety guidelines were 

generally met, and risk assessments were in compliance with VHA standards. 

Emergency Management 

VHA Handbook 1006.1 requires each CBOC to have a local policy or SOP defining how 

medical emergencies, including MH, are handled. The CBOC had policies that outlined 

management of medical and MH emergencies, and staff at each facility articulated 

responses that accurately reflected the local emergency response guidelines. 

VA OIG Office of Healthcare Inspections 7 
Springfield, Morehead City, Raleigh, Clarksville, Cookeville, Wichita Falls, and Klamath Falls 

B. VISN 6, Durham VAMC – Morehead City and Raleigh

CBOC Characteristics

Table 5 shows the characteristics of the Morehead City and Raleigh CBOCs. 

CBOC Characteristics Morehead City Raleigh

Type of CBOC VA Staffed VA Staffed 

Number of Uniques, FY 2010 4,083 8,769 

Number of Visits, FY 2010 19,898 37,045 

CBOC Size Mid-Size Large 

Locality Rural Urban 

FTE Provider(s) 3.50 8.30 

Type Providers Assigned Internal Medicine 

Physician 

PCP 

NP 

Psychologists 

Psychiatrists 

LCSW 

Internal Medicine 

Physician 

NP 

PA 

Psychiatrists 

LCSW 

Family Practitioners 

Ancillary Staff Assigned RN 

LPN 

Technologists 

Health Technician/ 

Medical Assistant 

RN 

LPN 

Pharmacist 

Social Worker 

Type of MH Providers Psychologists 

Psychiatrists 

LCSW 

Psychiatrists 

LCSW 

PCP 

Provides MH Services Yes Yes 

 Evening Hours No No 

 Weekends No No 

 Plan for Emergencies Outside of

Business Hours

Yes No 

 Provided Onsite Substance Use Disorder 

PTSD 

MST 

Psychosocial 

Rehabilitation 

PTSD 

 Referrals Another VA facility Another VA facility 

 Tele-Mental Health Medication management 

Individual Therapy 

No 

Remote Services None None 

Specialty Care Services Onsite Yes Yes 

 Type Dental 

Optometry 

Women’s Health 

Dermatology 

Women’s Health 

 Referrals Another VA facility Another VA facility 

Fee-basis or contract 

VA OIG Office of Healthcare Inspections 8 
Springfield, Morehead City, Raleigh, Clarksville, Cookeville, Wichita Falls, and Klamath Falls 

CBOC Characteristics (cont’d) Morehead City Raleigh

Ancillary Services Provided Onsite Laboratory 

EKG 

Laboratory 

EKG 

Miles to Parent Facility 170 35 

Table 5: CBOC Characteristics

Quality of Care Measures

DM 

Diabetes is the leading cause of new cases of blindness among adults age 20−74 and 

diabetic retinopathy causes 12,000 to 24,000 new cases of blindness each year. 

Detection and treatment of diabetic eye disease with laser therapy can reduce the 

development of severe vision loss by an estimated 50−60 percent. Table 6 displays the 

parent facility and the Morehead City and Raleigh CBOCs’ compliance in screening for 

retinopathy. 

Measure 

Meets 

Target Facility 

Qtr 3 

Numerator 

Qtr 3 

Denominator 

Qtr 3 

(%) 

DM – Retinal Eye 70% 558 Durham VAMC 58 63 91 

Exam 

558GC Morehead City CBOC 43 44 98 

558GB Raleigh CBOC 43 43 100 

Table 6. Retinal Exam, FY 2010

A1c is a blood test that measures average blood glucose (sugar) levels. Research 

studies in the United States and abroad have found that improved glycemic control 

benefits people with either type I or type II diabetes. In general, for every 1 percent 

reduction in A1c, the relative risk of developing microvascular diabetic complications 

(eye, kidney, and nerve disease) is reduced by 40 percent. The American Diabetes 

Association recommends an A1c of less than 7 percent. Patients with poorly controlled 

diabetes (A1c greater than 9 percent) are at higher risk of developing diabetic 

complications. Measuring A1c assesses the effectiveness of therapy. For this indicator, 

low scores indicate better compliance. Table 7 displays the scores of the parent facility 

and the Morehead City and Raleigh CBOCs. 

Meets Qtr 3 Qtr 3 Qtr 3 

Measure Target Facility Numerator Denominator (%) 

DM –A1c > 9 or not 22% 558 Durham VAMC 1,455 9,069 16 

done in past year 

558GC Morehead City CBOC 7 44 16 

558GB Raleigh CBOC 6 43 14 

Table 7. A1c Testing, FY 2010

VA OIG Office of Healthcare Inspections 9 
Springfield, Morehead City, Raleigh, Clarksville, Cookeville, Wichita Falls, and Klamath Falls 

Women’s Health 

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

with approximately 207,000 new cases reported each year. It is most common in 

women over 50. Women whose breast cancer is detected early have more treatment 

choices and better chances for survival. Screening by mammography (an x-ray of the 

breast) has been shown to reduce mortality by 20–30 percent among women 40 and 

older. Comparisons of the Morehead City and Raleigh CBOCs to the parent facility’s 

breast cancer screening are listed in Table 8. 

Meets Qtr 3 Qtr 3 Qtr 3 

Measure Target Facility Numerator Denominator (%) 

Mammography, 77% 558 Durham VAMC 3,301 3,786 88 

50-69 years old 

558GC Morehead City CBOC 25 29 86 

558GB Raleigh CBOC 19 23 83 

Table 8. Women’s Health, FY 2010

C&P

We reviewed the C&P files of five providers and the personnel folders of five nurses at 

the Morehead City CBOC and five providers and five nurses at the Raleigh CBOC. All 

providers possessed a full, active, current, and unrestricted license; and privileges were 

appropriate for services rendered. All nurses’ license and education requirements were 

verified and documented. Service-specific criteria for OPPE had been developed and 

approved. We found sufficient performance data to meet current requirements. OPPE 

included minimum competency criteria for privileges. 

Management of Laboratory Results

VHA Directive 2009-019 requires critical test results to be communicated to the ordering 

provider or surrogate provider within a timeframe that allows for prompt attention and 

appropriate clinical action to be taken. VHA also requires that the ordering provider 

communicate test results to patients so that they may participate in health care 

decisions. Each parent facility is required to develop a written policy for communicating 

test results to providers and documenting communications in the medical record, to 

include a system for surrogate providers to receive results when the ordering provider is 

not available. In addition, ordering providers are required to communicate outpatient 

test results (those not requiring immediate attention) to patients no later than 

14 calendar days from the date on which the results are available to the ordering 

provider. 

We reviewed the parent facility’s policies and procedures and the medical records of 

patients who had tests resulting in critical values and normal values. We determined 

that the facility had developed a written policy and had implemented an effective 

reporting process for test results. 

VA OIG Office of Healthcare Inspections 10 
Springfield, Morehead City, Raleigh, Clarksville, Cookeville, Wichita Falls, and Klamath Falls 

Critical Laboratory Results 

We found that the Morehead City and Raleigh CBOCs had effective processes in place 

to communicate critical laboratory test results to ordering providers and patients. We 

reviewed the medical records of 20 patients (10 at the Morehead City CBOC and 10 at 

the Raleigh CBOC) who had critical laboratory results and found that all records at the 

Morehead City CBOC and 9 records (90 percent) at the Raleigh CBOC contained 

documented evidence of patient notification and follow-up actions. 

Normal Laboratory Results 

We found that the Morehead City and Raleigh CBOCs had effective processes in place 

to communicate normal laboratory test results to patients. We reviewed the medical 

records of 20 patients (10 at the Morehead City CBOC and 10 at the Raleigh CBOC) 

who had normal laboratory results and found that all records at both CBOCs contained 

documented evidence of patient notification within 14 calendar days from the date the 

results were available to the ordering provider. 

Environment and Emergency Management

EOC 

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

general maintenance. Both CBOCs met most standards, and the environments were 

generally clean and safe. We found that the IC program monitored data and 

appropriately reported that data to relevant committees. Safety guidelines were 

generally met, and risk assessments were in compliance with VHA standards. 

Emergency Management 

VHA Handbook 1006.1 requires each CBOC to have a local policy or SOP defining how 

medical emergencies, including MH, are handled. Both CBOCs had policies that 

outlined management of medical and MH emergencies, and staff at each facility 

articulated responses that accurately reflected the local emergency response 

guidelines. 

VA OIG Office of Healthcare Inspections 11 
Springfield, Morehead City, Raleigh, Clarksville, Cookeville, Wichita Falls, and Klamath Falls 

C. VISN 9, Tennessee Valley HCS – Clarksville and Cookeville

CBOC Characteristics

Table 9 shows the characteristics of the Clarksville and Cookeville CBOCs. 

CBOC Characteristics Clarksville Cookeville

Type of CBOC VA Staffed Contract 

Number of Uniques, FY 2010 4,121 4,240 

Number of Visits, FY 2010 16,492 14,910 

CBOC Size Mid-Size Mid-Size 

Locality Urban Rural 

FTE Provider(s) 3.4 3 

Type Providers Assigned PCP 

NP 

PA 

Psychiatrists 

LCSW 

PCP 

NP 

Psychologists 

Psychiatrists 

Ancillary Staff Assigned RN 

LPN 

Pharmacist 

Social Worker 

Health Technician/ 

Medical Assistant 

RN 

LPN 

Technologists 

Health Technician/ 

Medical Assistant 

Type of MH Providers Psychiatrists 

NP/Clinical Nurse 

Specialist 

LCSW 

PCP 

Psychologists 

Psychiatrists 

Provides MH Services Yes Yes 

 Evening Hours No No 

 Weekends No No 

 Plan for Emergencies Outside of

Business Hours

No Yes 

 Provided Onsite Substance Use Disorder 

PTSD 

MST 

Homelessness 

Psychosocial 

Rehabilitation 

PTSD 

Psychosocial 

Rehabilitation 

 Referrals Another VA facility Another VA facility 

 Tele-Mental Health Medication Management Consultation 

Remote Services Tele-Retinal Tele-Medicine 

Specialty Care Services Onsite Yes No 

 Type Audiology NA 

 Referrals Another VA facility Another VA facility 

Fee-basis or contract 

VA OIG Office of Healthcare Inspections 12 
Springfield, Morehead City, Raleigh, Clarksville, Cookeville, Wichita Falls, and Klamath Falls 

CBOC Characteristics (cont’d) Clarksville Cookeville

Ancillary Services Provided Onsite Laboratory 

EKG 

Laboratory 

Radiology 

EKG 

Miles to Parent Facility 49 75 

Table 9: CBOC Characteristics

Quality of Care Measures

DM 

Diabetes is the leading cause of new cases of blindness among adults age 20−74 and 

diabetic retinopathy causes 12,000 to 24,000 new cases of blindness each year. 

Detection and treatment of diabetic eye disease with laser therapy can reduce the 

development of severe vision loss by an estimated 50−60 percent. Table 10 displays 

the parent facility’s and the Clarksville and Cookeville CBOCs’ compliance in screening 

for retinopathy. 

Measure 

Meets 

Target Facility 

Qtr 3 

Numerator 

Qtr 3 

Denominator 

Qtr 3 

(%) 

DM – Retinal Eye 70% 626 Tennessee Valley HCS 90 105 89 

Exam 

626GE Clarksville CBOC 46 48 96 

626GH Cookeville CBOC 38 45 84 

Table 10. Retinal Exam, FY 2010

A1c is a blood test that measures average blood glucose (sugar) levels. Research 

studies in the United States and abroad have found that improved glycemic control 

benefits people with either type I or type II diabetes. In general, for every 1 percent 

reduction in A1c, the relative risk of developing microvascular diabetic complications 

(eye, kidney, and nerve disease) is reduced by 40 percent. The American Diabetes 

Association recommends an A1c of less than 7 percent. Patients with poorly controlled 

diabetes (A1c greater than 9 percent) are at higher risk of developing diabetic 

complications. Measuring A1c assesses the effectiveness of therapy. For this indicator, 

low scores indicate better compliance. Table 11 displays the scores of the parent 

facility and the Clarksville and Cookeville CBOCs. 

Meets Qtr 3 Qtr 3 Qtr 3 

Measure Target Facility Numerator Denominator (%) 

DM –A1c > 9 or not 22% 626 Tennessee Valley HCS 11 106 12 

done in past year 

626GE Clarksville CBOC 5 48 10 

626GH Cookeville CBOC 4 45 9 

Table 11. A1c Testing, FY 2010

VA OIG Office of Healthcare Inspections 13 
Springfield, Morehead City, Raleigh, Clarksville, Cookeville, Wichita Falls, and Klamath Falls 

Women’s Health 

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

with approximately 207,000 new cases reported each year. It is most common in 

women over 50. Women whose breast cancer is detected early have more treatment 

choices and better chances for survival. Screening by mammography (an x-ray of the 

breast) has been shown to reduce mortality by 20–30 percent among women 40 and 

older. Comparisons of the Clarksville and Cookeville CBOCs to the parent facility’s 

breast cancer screening are listed in Table 12. 

Meets Qtr 3 Qtr 3 Qtr 3 

Measure Target Facility Numerator Denominator (%) 

Mammography, 77% 626 Tennessee Valley HCS 49 57 86 

50-69 years old 

626GE Clarksville CBOC 29 30 97 

626GH Cookeville CBOC 26 29 90 

Table 12. Women’s Health, FY 2010

C&P

We reviewed the C&P files of five providers and the personnel folders of four nurses at 

the Clarksville CBOC and five providers and four nurses at the Cookeville CBOC. All 

providers possessed a full, active, current, and unrestricted license; and privileges were 

appropriate for services rendered. All nurses’ license and education requirements were 

verified and documented. Service-specific criteria for OPPE had been developed and 

approved. We found sufficient performance data to meet current requirements. OPPE 

included minimum competency criteria for privileges. 

Management of Laboratory Results

VHA Directive 2009-019 requires critical test results to be communicated to the ordering 

provider or surrogate provider within a timeframe that allows for prompt attention and 

appropriate clinical action to be taken. VHA also requires that the ordering provider 

communicate test results to patients so that they may participate in health care 

decisions. Each parent facility is required to develop a written policy for communicating 

test results to providers and documenting communications in the medical record, to 

include a system for surrogate providers to receive results when the ordering provider is 

not available. In addition, ordering providers are required to communicate outpatient 

test results (those not requiring immediate attention) to patients no later than 

14 calendar days from the date on which the results are available to the ordering 

provider. 

We reviewed the parent facility’s CBOCs policies and procedures and the medical 

records of patients who had tests resulting in critical values and normal values. We 

determined that the facility and CBOC had developed a written policy and had 

implemented an effective reporting process for test results. 

VA OIG Office of Healthcare Inspections 14 
Springfield, Morehead City, Raleigh, Clarksville, Cookeville, Wichita Falls, and Klamath Falls 

Critical Laboratory Results 

We found that the Clarksville and Cookeville CBOCs had effective processes in place to 

communicate critical laboratory test results to ordering providers and patients. We 

reviewed the medical records of 20 patients (10 at the Clarksville CBOC and 10 at the 

Cookeville CBOC) who had critical laboratory results and found that all records 

contained documented evidence of patient notification and follow-up actions. 

Normal Laboratory Results 

We found that the Clarksville and Cookeville CBOCs had effective processes in place to 

communicate normal laboratory test results to patients. We reviewed the medical 

records of 20 patients (10 at the Clarksville CBOC and 10 at the Cookeville CBOC) and 

determined that the CBOCs had communicated normal results to 19 patients within 

14 calendar days from the date the results were available to the ordering provider. 

Environment and Emergency Management

EOC 

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

general maintenance. Both CBOCs met most standards, and the environments were 

generally clean and safe. We found that the IC program monitored data and 

appropriately reported that data to relevant committees. Safety guidelines were 

generally met, and risk assessments were in compliance with VHA standards. 

Emergency Management 

VHA Handbook 1006.1 requires each CBOC to have a local policy or SOP defining how 

medical emergencies, including MH, are handled. Both CBOCs had policies that 

outlined management of medical and MH emergencies, and staff at each facility 

articulated responses that accurately reflected the local emergency response 

guidelines. 

CBOC Contracts

Cookeville CBOC 

The contract for the Cookeville CBOC is administered through the 

Tennessee Valley HCS, Alvin C. York Campus, for primary medical care and MH 

services for all eligible veterans in VISN 9. Contracted services with Valor Healthcare, 

Inc., began on August 1, 2007, with a base year ending July 31, 2008, and 

2 option years extending the contract through July 31, 2010. The contract was 

extended for 6 months through January 31, 2011, pursuant to the provisions in the 

contract. At the time of our review, the CBOC was operating under a second contract 

extension that extended services through July 31, 2011. 

VA OIG Office of Healthcare Inspections 15 
Springfield, Morehead City, Raleigh, Clarksville, Cookeville, Wichita Falls, and Klamath Falls 

Contracted primary care services are provided by 3.0 FTE PCPs, composed of one 

physician and two NPs. The contractor was compensated at a monthly capitated rate 

per enrollee. The CBOC had 4,240 unique primary medical care enrollees with 

14,910 visits as reported on the FY 2010 CBOC Characteristics report (see Table 9). 

Contracted MH services are provided by 2.0 FTE MH providers, a psychiatrist and 

psychologist. The contractor was compensated at a monthly capitated rate per enrollee. 

There were 934 MH encounters at the CBOC for individual and group therapy sessions 

in 3 rd Qtr, FY 2010. 

We reviewed the contract to determine the contract payment terms, the services 

provided, the invoices submitted, and supporting information. We also performed 

inquiries of key Tennessee Valley HCS and contractor personnel. Our review focused 

on documents and records for the 3rd Qtr, FY 2010. We reviewed the methodology for 

tracking and reporting the number of enrollees in compliance with the terms of the 

contract. We reviewed paid capitation rates for compliance with the contract; form and 

substance of the contract invoices for ease of data analysis by the COTR; and 

duplicate, missing, or incomplete SSNs on the invoices. 

The VA PCMM Coordinator is responsible for maintaining currency of information in the 

PCMM database. The Tennessee Valley HCS has approximately 69,000 active patients 

with approximately 4,100 active patients assigned to the Cookeville CBOC. We 

reviewed PCMM data reported by VSSC and the Tennessee Valley HCS for compliance 

with VHA policies. We made inquiries about the number of patients who were 

unassigned, assigned to more than one PCP, or potentially deceased. 

Based on our review, we made the following observations, findings, and 

recommendations for the contract administration of primary care and MH, and the 

management of PCMM. Contract oversight responsibilities are divided between two 

people, a COTR for primary care services and a COTR for MH services. We commend 

the facility’s oversight of primary care through weekly and monthly meetings with the 

contractor, monitoring of performance measures, and an effective invoice validation 

process. The invoice validation process utilized lessens the risk of contractor 

overpayments by using VA data to determine the number of billable patients. The 

COTR for MH services provides oversight through quarterly peer reviews and periodic 

site visits. MH invoices were reviewed and found satisfactory; however, we found that 

key people responsible for oversight were not familiar with MH contract provisions, 

which raises the risk that contract provisions will not be monitored. 

We inquired about the large number of patients assigned to some of the primary care 

panels in PCMM, such as 1,600 assigned to one NP. We were told this has not resulted 

in reduced access to care and other performance measures. 

We noted the following: 

1.	 In the contract, an undefined phrase was used in the provision for payment that 

could lead to misinterpretation of a vesting visit. The contract states that each 

VA OIG Office of Healthcare Inspections 16 
Springfield, Morehead City, Raleigh, Clarksville, Cookeville, Wichita Falls, and Klamath Falls 

billable patient must have at least one “detailed medical evaluation every 

12 months,” where “detailed medical evaluation” has not been defined. 

2.	 Contracted services were improperly continued under a 6-month contract extension 

for the period February through July 2011. The contract had already been extended 

once for 6 months, and the contract stated that the base year and contract 

extensions cannot extend beyond January 31, 2011. The contract should have 

been extended under an interim contract authority. 

3.	 The MH invoice validation process does not provide assurance that the payment 

amount is accurate. We did not identify discrepancies; however, the current 

process samples approximately 20-30 out of 900 billable patients to validate MH 

encounters. This level of sampling would not give assurance payment amounts are 

accurate. The invoice review process could be improved by relying on VHA and not 

contractor provided data when validating the accuracy of total number of patients 

billed monthly to the VHA. 

4.	 We found that Tennessee Valley HCS PCMM panels had 2,661 patients with two or 

more PCPs assigned. VHA policy11 states that each patient must have only one 

assigned PCP within the VA system with some exceptions with approval. Patients 

with two or more PCPs assigned inflate primary care panel sizes and increase 

medical care costs for contracted care. The PCMM Coordinator is aware of this 

issue and has staff working to reduce the number of patients with two or more PCP 

assignments. 

Recommendation 4. We recommended that the VISN 9 Director ensures that contract 

pre-award process is performed with adequate time to ensure award before expiration 

of current contract. 

Recommendation 5. We recommended that the VISN 9 Director ensures that key 

contract terminology is clearly defined. 

Recommendation 6. We recommended the Tennessee Valley HCS Director ensures 

that staff providing oversight of contracted medical care have a clear understanding of 

the performance and payment provisions in the contract. 

Recommendation 7. We recommended that the Tennessee Valley HCS Director 

complies with VHA directives to maintain the accuracy of PCMM data to include 

reducing the number of patients assigned to more than one PCP. 

11 VHA Handbook 1101.02. 

VA OIG Office of Healthcare Inspections 17 
Springfield, Morehead City, Raleigh, Clarksville, Cookeville, Wichita Falls, and Klamath Falls 

D. VISN 16, Oklahoma City VAMC – Wichita Falls

CBOC Characteristics

Table 13 shows the characteristics of the Wichita Falls CBOC. 

CBOC Characteristics Wichita Falls

Type of CBOC Contract 

Number of Uniques, FY 2010 2,998 

Number of Visits, FY 2010 11,508 

CBOC Size Mid-Size 

Locality Urban 

FTE Provider(s) 1.50 

Type Providers Assigned PCP 

PA 

Psychologist 

LCSW 

Ancillary Staff Assigned RN 

LPN 

Social Worker 

Technician/Technologists 

Type of MH Providers Psychologists 

LCSW 

Provides MH Services Yes 

 Evening Hours No 

 Weekends No 

 Plan for Emergencies Outside of Business Hours Yes 

 Provided Onsite General MH services 

Substance Use Disorder 

PTSD 

MST 

 Referrals None 

 Tele-Mental Health Medication management 

Remote Services Tele-Retinal Imaging 

Specialty Care Services Onsite Yes 

 Type Women’s Health 

 Referrals Another VA facility 

Fee-basis or contract 

Ancillary Services Provided Onsite Laboratory 

Miles to Parent Facility 142 

Table 13: CBOC Characteristics

VA OIG Office of Healthcare Inspections 18 
 

 

Springfield, Morehead City, Raleigh, Clarksville, Cookeville, Wichita Falls, and Klamath Falls 

Quality of Care Measures

DM 

Diabetes is the leading cause of new cases of blindness among adults age 20−74 and 

diabetic retinopathy causes 12,000 to 24,000 new cases of blindness each year. 

Detection and treatment of diabetic eye disease with laser therapy can reduce the 

development of severe vision loss by an estimated 50−60 percent. Table 14 displays 

the parent facility’s and the Wichita Falls CBOC’s compliance in screening for 

retinopathy. 

Measure 

Meets 

Target Facility 

Qtr 3 

Numerator 

Qtr 3 

Denominator 

Qtr 3 

(%) 

DM – Retinal Eye 

Exam 

70% 635 Oklahoma City VAMC 93 101 94 

635GB Wichita Falls CBOC 37 47 79 

Table 14. Retinal Exam, FY 2010

A1c is a blood test that measures average blood glucose (sugar) levels. Research 

studies in the United States and abroad have found that improved glycemic control 

benefits people with either type I or type II diabetes. In general, for every 1 percent 

reduction in A1c, the relative risk of developing microvascular diabetic complications 

(eye, kidney, and nerve disease) is reduced by 40 percent. The American Diabetes 

Association recommends an A1c of less than 7 percent. Patients with poorly controlled 

diabetes (A1c greater than 9 percent) are at higher risk of developing diabetic 

complications. Measuring A1c assesses the effectiveness of therapy. For this indicator, 

low scores indicate better compliance. Table 15 displays the scores of the parent 

facility and the Wichita Falls CBOC. 

Measure 

Meets 

Target Facility 

Qtr 3 

Numerator 

Qtr 3 

Denominator 

Qtr 3 

(%) 

DM –A1c > 9 or not 

done in past year 

29% 635 Oklahoma City VAMC 11 101 12 

635GB Wichita Falls CBOC 11 47 23 

Table 15. A1c Testing, FY 2010

Women’s Health 

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

with approximately 207,000 new cases reported each year. It is most common in 

women over 50. Women whose breast cancer is detected early have more treatment 

choices and better chances for survival. Screening by mammography (an x-ray of the 

breast) has been shown to reduce mortality by 20–30 percent among women 40 and 

older. Comparison of the Wichita Falls CBOC to the parent facility’s breast cancer 

screening is listed in Table 16. 

VA OIG Office of Healthcare Inspections 19 
Springfield, Morehead City, Raleigh, Clarksville, Cookeville, Wichita Falls, and Klamath Falls 

Measure 

Meets 

Target Facility 

Qtr 3 

Numerator 

Qtr 3 

Denominator 

Qtr 3 

(%) 

Mammography, 

50-69 years old 

77% 635 Oklahoma City VAMC 27 37 71 

635GB Wichita Falls CBOC 20 28 71 

Table 16. Women’s Health, FY 2010

The CBOC manager reported that most results were available through the contractor’s 

computer system. Providers have access to the contractor’s computer system at the 

CBOC; however, the mammogram reports were not available in CPRS. The CBOC 

manager reported that a fulltime employee was recently hired to manually enter results 

into CPRS. 

C&P

We reviewed the C&P files of five providers and the personnel folders of three nurses at 

the Wichita Falls CBOC. All providers possessed a full, active, current, and unrestricted 

license. All nurses’ license and education requirements were verified and documented. 

Service-specific criteria for OPPE had been developed and approved. However, we 

found the following area that needed improvement. 

OPPE 

We found that two of five provider profiles did not contain OPPE data. OPPEs allow the 

facility to identify professional practice trends that impact the quality of care and patient 

safety. OPPEs also serve as a mechanism for providers to assess their performance in 

relation to those with comparable privileges and seek avenues for improvement, if 

warranted. 

Recommendation 8. We recommended that adequate competency data is maintained 

in all providers’ profiles. 

Management of Laboratory Results

VHA Directive 2009-019 requires critical test results to be communicated to the ordering 

provider or surrogate provider within a timeframe that allows for prompt attention and 

appropriate clinical action to be taken. VHA also requires that the ordering provider 

communicate test results to patients so that they may participate in health care 

decisions. Each parent facility is required to develop a written policy for communicating 

test results to providers and documenting communications in the medical record, to 

include a system for surrogate providers to receive results when the ordering provider is 

not available. In addition, ordering providers are required to communicate outpatient 

test results (those not requiring immediate attention) to patients no later than 

14 calendar days from the date on which the results are available to the ordering 

provider. 

VA OIG Office of Healthcare Inspections 20 
Springfield, Morehead City, Raleigh, Clarksville, Cookeville, Wichita Falls, and Klamath Falls 

We reviewed the parent facility’s policies and procedures, and the medical records of 

patients who had tests resulting in critical values and normal values. We found the 

following areas that needed improvement. 

Critical Laboratory Results 

We found that the Wichita Falls CBOC did not have an effective process in place to 

communicate critical laboratory test results to patients. We reviewed the medical 

records of 10 patients who had critical laboratory results and found that 6 (60 percent) 

records contained documented evidence of patient notification and follow-up actions. 

Recommendation 9. We recommended that the ordering provider document patient 

notification and follow-up actions in response to critical results at the Wichita Falls 

CBOC. 

Normal Laboratory Results 

We found that the Wichita Falls CBOC did not have an effective process in place to 

communicate normal laboratory test results to patients. We reviewed the medical 

records of 10 patients and determined that the CBOC had communicated normal results 

to only 1 (10 percent) patient within 14 calendar days from the date the result was 

available to the ordering provider. 

Recommendation 10. We recommended that normal test results are consistently 

communicated to patients within the specified timeframe at the Wichita Falls CBOC. 

Environment and Emergency Management

EOC 

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

general maintenance. The Wichita Falls CBOC met most standards, and the 

environment was generally clean and safe. We found that the IC program monitored 

data and appropriately reported that data to relevant committees. Safety guidelines 

were generally met, and risk assessments were in compliance with VHA standards. We 

found one process that needed improvement. 

Medical Records 

We found that managers at the Wichita Falls CBOC did not ensure the report entry of 

radiology exams and laboratory tests into the CPRS. According to VHA policy,12 CPRS 

is the primary electronic health record where patient information is documented. 

Further, the contract states that laboratory and radiology results must be entered into 

CPRS. Managers acknowledged this variance and reported that a fulltime employee 

was hired to manually enter results of laboratory and radiology services into CPRS. 

12 VHA Handbook 1907.01, Health Management and Health Records, August 25, 2006. 

VA OIG Office of Healthcare Inspections 21 
Springfield, Morehead City, Raleigh, Clarksville, Cookeville, Wichita Falls, and Klamath Falls 

Recommendation 11. We recommended that reports of radiology exams and 

laboratory tests be consistently entered into CPRS at the Wichita Falls CBOC. 

Emergency Management 

VHA Handbook 1006.1 requires each CBOC to have a local policy or standard 

operating procedure(s) defining how medical emergencies, including MH, are handled. 

The Wichita Falls CBOC had policies that outlined management of medical and MH 

emergencies. Our interviews revealed staff articulated responses that accurately 

reflected the local emergency response guidelines. 

CBOC Contracts

Wichita Falls CBOC 

The contract for the Wichita Falls CBOC is administered through the Oklahoma City 

VAMC for primary medical and MH care for all eligible veterans in VISN 16 and was 

awarded competitively to United Regional Healthcare System for a base year that 

began on January 1, 2005, and ended December 31, 2005. With two 1-year option 

periods, the contract was to expire on December 31, 2007. However, it was modified on 

June 26, 2008, with an effective date of May 1, 2008, to add: 1) 2 additional option 

years with increased pricing; 2) 1.5 FTE for a MH staff to include a social worker and a 

program support administrative clerk; and 3) leased space for MH services. This 

modification extended the contract through December 31, 2009. The contract was 

modified again with an effective date of November 2, 2009, to extend the contract an 

additional 6 months to “allow time for bid preparation and award of new contract.” The 

payment terms of the original contract included a monthly capitated rate per enrollee for 

primary care patients and an hourly rate for MH services. The CBOC had 2,998 unique 

primary medical care enrollees with 11,508 visits as reported on the FY 2010 CBOC 

Characteristics report (see Table 13). 

MH services are provided onsite by a VA psychologist with the contractor providing 

support staff (social worker and program administrator). The VA psychologist also 

provides tele-mental health services to other CBOCs. When needed, Oklahoma City 

VAMC provides a psychiatrist for tele-mental health services for patients at the 

Wichita Falls CBOC. The VA leases the office space from the contractor to 

accommodate the MH services. There were 596 MH encounters at the CBOC during 

the 3rd Qtr, FY 2010. 

We reviewed the contract to determine the payment terms, the services provided, the 

invoices submitted, and supporting information. We also performed inquiries of key 

Oklahoma City VAMC and contractor personnel. Our review focused on documents and 

records for the 3rd Qtr, FY 2010. We reviewed the methodology for tracking and 

reporting the number of enrollees in compliance with the terms of the contract. We 

reviewed paid capitation rates for compliance with the contract; form and substance of 

the contract invoices for ease of data analysis by the COTR; and duplicate, missing, or 

VA OIG Office of Healthcare Inspections 22 
Springfield, Morehead City, Raleigh, Clarksville, Cookeville, Wichita Falls, and Klamath Falls 

incomplete SSNs on the invoices. 

The VA PCMM Coordinator is responsible for maintaining currency of information in the 

PCMM database. The Oklahoma City VAMC has approximately 43,000 active patients 

with approximately 2,700 active patients assigned to the Wichita Falls CBOC. We 

reviewed PCMM data reported by VSSC and the Oklahoma City VAMC for compliance 

with VHA policies. We made inquiries with the PCMM Coordinator to determine the 

accuracy of the PCP panel sizes reported in the PCMM database. 

We noted the following: 

1.	 Performance measures and patient satisfaction are not being monitored to track 

eligibility for incentives or penalties as stated in the contract. We found that the 

contractor did not meet certain performance measures; therefore, penalties should 

have been enforced according to the contract. The amount of penalties for the 

3rd Qtr, FY 2010 was about $7,200. The contractor did not meet these performance 

measures the entire fiscal year, which would have resulted in additional penalties 

estimated at $18,700. 

2.	 There were two contract modifications that added new services and expenses, which 

were outside of the scope of the original contract. The new requirements included: 

1) furnished leased space, 2) additional staff to be paid for by the VA, 3) additional IT 

equipment, and 4) an annual rate increase for both primary care and MH services 

during the extension periods. These requirements represent a cardinal change to 

the contract, which should have been re-competed and a new contract awarded. 

3.	 The contract modification to extend the 3-year contract by adding 2 years was not 

appropriate. The contract contains Federal Acquisition Requirement clause 

52.217-9, Option to Extend the Term of the Contract, allows the CO to exercise the 

awarded option years. However, it does not allow the CO to add new option years. 

The maximum term of this contract should have been 3 years. 

4.	 There was a 4-month period between January 2008 and April 2008 where there was 

no contract in place. The original contract expired on December 31, 2007. An 

extension on the contract with an effective date of May 1, 2008, was signed on 

June 26, 2008. 

5.	 The contract statement of work includes a provision for a waiting period of less than 

30 minutes that conflicts with VHA directive which states “patients must be seen by a 

provider within 20 minutes of their scheduled appointment.”13 

6.	 The number of enrollees invoiced exceeded the maximum workload limitation of 

2600 as required by the contract. The number of enrollees invoiced averaged more 

than 2,700 in the 3rd Qtr, FY 2010. 

13 VHA Directive 2006-041, Veterans Health Care Service Standards, June 27, 2006. 

VA OIG Office of Healthcare Inspections 23 
Springfield, Morehead City, Raleigh, Clarksville, Cookeville, Wichita Falls, and Klamath Falls 

7.	 The number of the patients assigned to PCPs in PCMM was significantly less than 

the number invoiced. For the month of June 2010, the difference between the 

patients assigned (2,003) and patients invoiced (2,742) is 739 patients. This 

difference was due to one PCP and his assigned patients that were incorrectly 

coded to the parent facility in PCMM but should have been coded to the Wichita 

Falls CBOC. 

8.	 There were 1,367 patients assigned to an Oklahoma City VAMC PCP in PCMM that 

were also assigned to an additional PCP at other facilities. The PCMM Handbook 

states that each patient must have only one assigned PCP within the VA system 

unless approval has been obtained for more than one provider.14 The Oklahoma 

City VAMC had 48 patients that were approved to have more than one PCP. 

Recommendation 12. We recommended that the Oklahoma City VAMC Director 

ensures that contract oversight includes the monitoring of performance measures and 

enforcement of incentives and penalties when applicable, as required per the contract. 

Recommendation 13. We recommended that the VISN 16 Director ensures that 

contract requirements and modifications, including extensions, are appropriate and 

consistent with the federal acquisition requirements. 

Recommendation 14. We recommended that the Oklahoma City VAMC Director take 

appropriate action to ensure the accuracy of reported PCMM data is in accordance with 

the PCMM Handbook. 

14 VHA Handbook 1101.02. 

VA OIG Office of Healthcare Inspections 24 
Springfield, Morehead City, Raleigh, Clarksville, Cookeville, Wichita Falls, and Klamath Falls 

E. VISN 20, Southern Oregon Rehabilitation

Center and Clinics – Klamath Falls

CBOC Characteristics

Table 17 shows the characteristics of the Klamath Falls CBOC. 

CBOC Characteristics Klamath Falls

Type of CBOC VA Staffed 

Number of Uniques, FY 2010 2,631 

Number of Visits, FY 2010 15,788 

CBOC Size Mid-Size 

Locality Rural 

FTE Provider(s) 2.33 

Type Providers Assigned PCP 

NP 

Ancillary Staff Assigned RN 

LPN 

Health Technician/Medical Assistant 

Type of MH Providers NP/Clinical Nurse Specialist 

Provides MH Services Yes 

 Evening Hours No 

 Weekends No 

 Plan for Emergencies Outside of Business Hours No 

 Provided Onsite Medication Management 

 Referrals None 

 Tele-Mental Health Medication Management 

Individual Therapy 

Group Therapy 

Remote Services Tele-medicine 

Tele-dermatology 

Specialty Care Services Onsite No 

 Type NA 

 Referrals Another VA facility 

Fee-basis or contract 

Ancillary Services Provided Onsite Laboratory 

EKG 

Outreach Clinic Lakeview Outreach Clinic 

Miles to Parent Facility 90 

Table 17: CBOC Characteristics

Quality of Care Measures

DM 

Diabetes is the leading cause of new cases of blindness among adults age 20−74 and 

diabetic retinopathy causes 12,000 to 24,000 new cases of blindness each year. 

Detection and treatment of diabetic eye disease with laser therapy can reduce the 

VA OIG Office of Healthcare Inspections 25 
 

Springfield, Morehead City, Raleigh, Clarksville, Cookeville, Wichita Falls, and Klamath Falls 

development of severe vision loss by an estimated 50−60 percent. Table 18 displays 

the parent facility and the Klamath Falls CBOC’s compliance in screening for 

retinopathy. 

Measure 

Meets 

Target Facility 

Qtr 3 

Numerator 

Qtr 3 

Denominator 

Qtr 3 

(%) 

DM – Retinal Eye 

Exam 

70% 692 SORCC 53 59 93 

692GA Klamath Falls CBOC 12 15 80 

Table 18. Retinal Exam, FY 2010

A1c is a blood test that measures average blood glucose (sugar) levels. Research 

studies in the United States and abroad have found that improved glycemic control 

benefits people with either type I or type II diabetes. In general, for every 1 percent 

reduction in A1c, the relative risk of developing microvascular diabetic complications 

(eye, kidney, and nerve disease) is reduced by 40 percent. The American Diabetes 

Association recommends an A1c of less than 7 percent. Patients with poorly controlled 

diabetes (A1c greater than 9 percent) are at higher risk of developing diabetic 

complications. Measuring A1c assesses the effectiveness of therapy. For this 

indicator, low scores indicate better compliance. Table 19 displays the scores of the 

parent facility and the Klamath Falls CBOC. 

Measure 

Meets 

Target Facility 

Qtr 3 

Numerator 

Qtr 3 

Denominator 

Qtr 3 

(%) 

DM –A1c > 9 or not 

done in past year 

20% 692 SORCC 7 59 14 

692GA Klamath Falls CBOC 1 15 7 

Table 19. A1c Testing, FY 2010

Women’s Health 

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

with approximately 207,000 new cases reported each year. It is most common in 

women over 50. Women whose breast cancer is detected early have more treatment 

choices and better chances for survival. Screening by mammography (an x-ray of the 

breast) has been shown to reduce mortality by 20–30 percent among women 40 and 

older. The parent facility’s breast cancer screening results are listed in Table 20. The 

Klamath Falls CBOC had no patients who met the criteria for our review; therefore, we 

were not able to compare the CBOC to the parent facility’s score. 

Measure 

Meets 

Target Facility 

Qtr 3 

Numerator 

Qtr 3 

Denominator 

Qtr 3 

(%) 

Mammography, 

50-69 years old 

77% 692 SORCC 25 28 89 

692GA Klamath Falls CBOC NA NA NA 

Table 20. Women’s Health, FY 2010

VA OIG Office of Healthcare Inspections 26 
Springfield, Morehead City, Raleigh, Clarksville, Cookeville, Wichita Falls, and Klamath Falls 

C&P

We reviewed the C&P files of four providers and the personnel folders of five nurses at 

the Klamath Falls CBOC. All providers possessed a full, active, current and 

unrestricted license. All nurses’ license and education requirements were verified and 

documented. However, we found the following area that required improvement: 

Performance Improvement Data 

We did not find measurable performance data to support reprivileging in the four 

provider profiles reviewed. VHA policy requires specific competency criteria in OPPEs 

for all privileged physicians.15 

Recommendation 15. We recommended that measurable performance data is 

maintained in all provider profiles to support physician reprivileging at the Klamath Falls 

CBOC. 

Management of Laboratory Results

VHA Directive 2009-019 requires critical test results to be communicated to the ordering 

provider or surrogate provider within a timeframe that allows for prompt attention and 

appropriate clinical action to be taken. VHA also requires that the ordering provider 

communicate test results to patients so that they may participate in health care 

decisions. Each parent facility is required to develop a written policy for communicating 

test results to providers and documenting communications in the medical record, to 

include a system for surrogate providers to receive results when the ordering provider is 

not available. In addition, ordering providers are required to communicate outpatient 

test results (those not requiring immediate attention) to patients no later than 

14 calendar days from the date on which the results are available to the ordering 

provider. 

We reviewed the parent facility’s policies and procedures and the medical records of 

patients who had tests resulting in critical values and normal values. We found the 

following, with one process that needed improvement. 

Critical Laboratory Results 

We found that the Klamath Falls CBOC had effective processes in place to 

communicate critical laboratory test results to ordering providers and patients. We 

reviewed the medical records of four patients who had critical laboratory results and 

found that all the records contained documented evidence of patient notification and 

follow-up actions. 

15 VHA Handbook 1100.19. 

VA OIG Office of Healthcare Inspections 27 
Springfield, Morehead City, Raleigh, Clarksville, Cookeville, Wichita Falls, and Klamath Falls 

Normal Laboratory Results 

We found that the Klamath Falls CBOC did not have processes in place to 

communicate normal laboratory test results to patients. We reviewed the medical 

records of 10 patients and determined that the Klamath Falls CBOC had communicated 

normal results to 7 (70 percent) patients within 14 calendar days from the date the 

results were available to the ordering provider. 

Recommendation 16. We recommended that normal test results are consistently 

communicated to patients within the specified timeframe at the Klamath Falls CBOC. 

Environment and Emergency Management

EOC 

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

general maintenance. The clinic met standards, and the environments were generally 

clean and safe. We found that the IC program monitored data and appropriately 

reported that data to relevant committees. Safety guidelines were generally met, and 

risk assessments were in compliance with VHA standards. 

Emergency Management 

VHA Handbook 1006.1 requires each CBOC to have a local policy or SOP defining how 

medical emergencies, including MH, are handled. The CBOC had policies that outlined 

management of medical and MH emergencies. Our interviews revealed staff articulated 

responses that accurately reflected the local emergency response guidelines. 

VA OIG Office of Healthcare Inspections 28 
Springfield, Morehead City, Raleigh, Clarksville, Cookeville, Wichita Falls, and Klamath Falls 

Appendix A

VISN 1 Director Comments

Department of

Veterans Affairs Memorandum

Date: May 23, 2011
 

From: Director, VISN 1 (10N1)
 

Subject: CBOC Review: Springfield, MA
 

To: Director, Bedford Office of Healthcare Inspections (54BN)
 

Director, Management Review Services (VHA 10A4A4) 

I have reviewed the findings and recommendations and concur. Our 

actions to the recommendations are attached. 

Michael Mayo-Smith, MD, MPH 

Network Director 

VA OIG Office of Healthcare Inspections 29 
Springfield, Morehead City, Raleigh, Clarksville, Cookeville, Wichita Falls, and Klamath Falls 

Appendix B

Northampton VAMC Director Comments

Department of

Veterans Affairs Memorandum

Date: May 23, 2011 

From: Director, Northampton VAMC (631/00) 

Subject: CBOC Review: Springfield, MA 

To: Director, VISN 1 (10N1) 

I have reviewed the draft report for the CBOC Review of the Springfield 

Outpatient Clinic conducted during the week of March 7, 2011. We concur 

with the recommendations and have already initiated corrective actions. 

If you have any questions regarding our responses and actions to the 

recommendations in the draft report, please contact me at (413) 582­

3000. 

Roger Johnson 

Director 

VA OIG Office of Healthcare Inspections 30 
Springfield, Morehead City, Raleigh, Clarksville, Cookeville, Wichita Falls, and Klamath Falls 

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 the C&P Committee grants privileges 

appropriate for the services provided at the Springfield CBOC. 

Concur 

Target date for completion: July 31, 2011 

Effective immediately, the C&P Committee will ensure that all requests for privileges of 

providers practicing at the Springfield CBOC are appropriate for services provided at 

that site. To ensure full implementation of this process, all privilege request documents 

will be revised to include designation of setting specific privileges. Target date for full 

implementation is July 31, 2011. 

Recommendation 2. We recommended that the C&P Committee documents adequate 

discussion of providers’ PI data prior to reprivileging at the Springfield CBOC. 

Concur 

Target date for completion: August 5, 2011 

The Credentialing and Privileging Committee minute process was revised to reflect 

discussion of performance data used to make privileging and re-privileging decisions. 

Quality Management will monitor minutes for compliance. 

Recommendation 3. We recommended that managers implement a plan to improve 

communication of normal test results to patients and monitor compliance at the 

Springfield CBOC. 

Concur 

Target date for completion: September 1, 2011 

A multi-disciplinary task group was formed to ensure patient notification of normal test 

results as defined in VHA Directive 2009-019 and to develop a monitoring process. 

Specific strategies in process include: review of sample of tests completed in 

March 2011 by service lines to establish baseline performance; identification of best 

practices used by other facilities; develop facility policy that is in compliance with VHA 

Directive 2009-019; staff education of requirements and service line roll out; initiate 

periodic monitoring of this process. 

VA OIG Office of Healthcare Inspections 31 
Springfield, Morehead City, Raleigh, Clarksville, Cookeville, Wichita Falls, and Klamath Falls 

Appendix C

VISN 6 Director Comments

Department of

Veterans Affairs Memorandum

Date: May 23, 2011
 

From: Network Director, VA Mid-Atlantic Health Care Network,
 

VISN 6 (10N6) 

Subject: CBOC Reviews: Morehead City and Raleigh, NC 

To: Director, Washington DC Healthcare Inspections Division 

(54DC)
 

Director, Management Review Services (VHA 10A4A4)
 

1. This memo is to acknowledge receipt of the draft report for the review 

of the Morehead City and Raleigh, NC Community Based Outpatient 

Clinics. 

2. If there are questions, please contact Ralph Gigliotti, Director, Durham 

VA Medical Center, at 919-286-6903. 

/s Augustin A. Davila 

for 

DANIEL F. HOFFMANN, FACHE 

VA OIG Office of Healthcare Inspections 32 
Springfield, Morehead City, Raleigh, Clarksville, Cookeville, Wichita Falls, and Klamath Falls 

Appendix D

Durham VAMC Director Comments

Department of

Veterans Affairs Memorandum

Date: May 13, 2011 

From: Director, Durham VAMC (558/00) 

Subject: CBOC Reviews: Morehead City and Raleigh, NC 

To: Director, VISN 6 (10N6) 

This memo serves to acknowledge receipt and review of the draft report 

for the Morehead City and Raleigh, NC Community Based Outpatient 

Clinics. Thank you for reviewing these two facilities for the selected 

activities and validating that they are providing consistent, safe, highquality health care, in accordance with VA policies. If you have any 

questions, please do not hesitate to contact Jane Penny, MSN, CPHQ, 

Chief of Quality Management at 919-286-0411 ext 6970 

(Original signed) 

Ralph T. Gigliotti, FACHE 

VA OIG Office of Healthcare Inspections 33 
Springfield, Morehead City, Raleigh, Clarksville, Cookeville, Wichita Falls, and Klamath Falls 

Appendix E

VISN 9 Director Comments

Department of

Veterans Affairs Memorandum

Date: May 20, 2011 

From: Director, VISN 9 (10N9) 

Subject: CBOC Reviews: Clarksville and Cookeville, TN 

To: Director, Atlanta Office of Healthcare Inspections Division 

(54AT)
 

Director, Management Review Services (VHA 10A4A4)
 

1. I concur with the report and have no comments. 

2. Should you need additional information, please contact 

Tammy Williams, VISN 9 Continuous Readiness Coordinator 

at (615) 695-2200. 

original signed
 

John Dandridge, Jr.
 

Director, VA Mid South Healthcare Network (10N9)
 

VA OIG Office of Healthcare Inspections 34 
Springfield, Morehead City, Raleigh, Clarksville, Cookeville, Wichita Falls, and Klamath Falls 

Appendix F

Tennessee Valley HCS Director Comments

Department of

Veterans Affairs Memorandum

Date: May 20, 2011 

From: Director, Tennessee Valley HCS (626/00) 

Subject: CBOC Reviews: Clarksville and Cookeville, TN 

To: Director, VISN 9 (10N9) 

I concur with the subject Office of Inspector 

inspection report and have no comments. 

General’s 

original signed
 

Juan A. Morales, RN, MSN
 

Director, Tennessee Valley Healthcare System (626/00)
 

VA OIG Office of Healthcare Inspections 35 
Springfield, Morehead City, Raleigh, Clarksville, Cookeville, Wichita Falls, and Klamath Falls 

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 4. We recommended that the VISN 9 Director ensures that contract 

pre-award process is performed with adequate time to ensure award before expiration 

of current contract. 

Concur 

Target date for completion: September 30, 2011 

 Staffing is being increased due to shortage of personnel. This should prevent 

last minute extensions. 

 The SAO (Service Area Office) Central has generated a template for more 

complex solicitations, including the CBOC requirements. 

 The OIG suggestions will be forwarded to the SAO point of contact for 

consideration. 

Recommendation 5. We recommended that the VISN 9 Director ensures that key 

contract terminology is clearly defined. 

Concur 

Target date for completion: Completed 

	 New Statements of Work have been revised defining specific level 3 codes and 

E&M vesting codes. 

Recommendation 6. We recommended the Tennessee Valley HCS Director ensures 

that staff providing oversight of contracted medical care have a clear understanding of 

the performance and payment provisions in the contract. 

Concur 

Target date for completion: Completed 

	 The Contracting Officer Technical Representative (COTR) will complete all 

mandatory training and show evidence of competency to remain certified as a 

COTR. 

 COTRs will work with the Contracting Officer on all contracting issues. 

 The COTR will verify and certify all related invoices of services provided by the 

Contractor. 

VA OIG Office of Healthcare Inspections 36 
Springfield, Morehead City, Raleigh, Clarksville, Cookeville, Wichita Falls, and Klamath Falls 

	 The new CBOC contract verbiage has been re-vamped to avoid vague or unclear 

language concerning payments per enrollee or other critical features. 

Recommendation 7. We recommended that the Tennessee Valley HCS Director 

complies with VHA directives to maintain the accuracy of PCMM data to include 

reducing the number of patients assigned to more than one PCP. 

Concur 

Target date for completion: Ongoing, due to fluid process and involvement of other VA 

entities. 

	 TVHS is currently in compliance with VHA Handbook 1101.02. TVHS has no 

dual PCP assignments within TVHS. 

	 An ongoing review process is actively being used to identify and address the 

number of patients dually assigned to our facility as well as another facility 

throughout the nation. The numbers of duplicates have continued to decrease 

each month. The current level number is: 2300 as of May 2011. 

	 Many of these dual assignments cannot be updated by our local PCMM 

Coordinator as they require manual clean-up actions by another facility within the 

VA. We continue to make contact and request these actions be completed. 

VA OIG Office of Healthcare Inspections 37 
Springfield, Morehead City, Raleigh, Clarksville, Cookeville, Wichita Falls, and Klamath Falls 

Appendix G

VISN 16 Director Comments

Department of

Veterans Affairs Memorandum

Date: May 24, 2011 

From: Director, VISN 16 (10N16) 

Subject: CBOC Review: Wichita Falls, TX 

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

Director, Management Review Services (VHA 10A4A4) 

1.	 The South Central VA Health Care Network (VISN 16) has reviewed 

the response from the Oklahoma City VA Medical Center and concurs 

with the response. 

2.	 If you have any questions, please contact Adrienne Riesenbeck, 

Director, Office of Performance and Quality, at (405) 456-3146. 

VA OIG Office of Healthcare Inspections 38 
Springfield, Morehead City, Raleigh, Clarksville, Cookeville, Wichita Falls, and Klamath Falls 

Appendix H

Oklahoma City VAMC Director Comments

Department of

Veterans Affairs Memorandum

Date: May 24, 2011 

From: Director, Oklahoma City VAMC (635/00) 

Subject: CBOC Review: Wichita Falls, TX 

To: Director, VISN 16 (10N16) 

1.	 We appreciate the opportunity to work with the Office of the Inspector 

General as we continuously strive to improve the quality of healthcare 

for America’s Veterans. 

2.	 I concur with the findings and recommendations of the OIG CBOC 

review team. 

3.	 If you have any questions, please contact Adrienne Riesenbeck, 

Director, Office of Performance and Quality at (405)456-3146. 

David P. Wood, MHA, FACHE
 

Oklahoma City VAMC Director
 

VA OIG Office of Healthcare Inspections 39 
Springfield, Morehead City, Raleigh, Clarksville, Cookeville, Wichita Falls, and Klamath Falls 

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 8. We recommended that adequate competency data is maintained
 

in all providers’ profiles.
 

Concur
 

Target date for completion: June 30, 2011
 

OPPE criteria and data will be reviewed by the Credentialing Committee (PSB) to
 

ensure adequate data is maintained in all physicians’ profiles. The OPPE data will then
 

be reviewed by the SPICE Committee with actions taken as appropriate.
 

Recommendation 9. We recommended that the ordering provider document patient
 

notification and follow-up actions in response to critical results at the Wichita Falls
 

CBOC.
 

Concur
 

Target date for completion: June 30, 2011
 

A task group was convened to address documentation of patient notification and
 

treatment actions in response to critical results. Random chart reviews will be
 

conducted to monitor compliance.
 

Recommendation 10. We recommended that normal test results are consistently
 

communicated to patients within the specified timeframe at the Wichita Falls CBOC.
 

Concur
 

Target date for completion: June 30, 2011
 

A task group was convened to address the timely notification of normal test results in
 

accordance with VA requirements. The notification will be documented in the medical
 

record. Random chart reviews will be conducted to monitor compliance.
 

Recommendation 11. We recommended that reports of radiology exams and
 

laboratory tests are consistently entered into CPRS at the Wichita Falls CBOC.
 

Concur
 

Target date for completion: Complete
 

VA OIG Office of Healthcare Inspections 39 
Springfield, Morehead City, Raleigh, Clarksville, Cookeville, Wichita Falls, and Klamath Falls 

Radiology exam reports are now scanned by the clinic into CPRS within 48 hours of 

receipt. A part-time Oklahoma City VAMC laboratory clerk is now assigned the duty of 

entering the lab results into CPRS within 7 days of receipt from United Regional Health 

Care System of Wichita Falls. Quarterly monitoring is now conducted to ensure 

compliance. 

Recommendation 12. We recommended that the Oklahoma City VAMC Director 

ensures that contract oversight includes the monitoring of performance measures and 

enforcement of incentives and penalties when applicable, as required per the contract. 

Concur 

Target date for completion: Complete 

Senior leadership at the Oklahoma City VAMC met with senior leadership of United 

Regional Health Care System of Wichita Falls to review current performance of the 

Wichita Falls CBOC. Specific plans were developed to enforce incentives and penalties 

when applicable, as required by the contract. Monthly reviews to ensure compliance 

with the contract in relation to performance measures are conducted, and issues with 

noncompliance are forwarded to the Contracting Officer for follow-up. 

Recommendation 13. We recommended that the VISN 16 Director ensures that 

contract requirements and modifications, including extensions, are appropriate and 

consistent with the federal acquisition requirements. 

Concur 

Target date for completion: Complete 

A semi-annual review of all contracts is conducted by the Acquisition and Contract 

Management Committee. The purpose of the review is to ensure all contracts and 

agreements meet established timelines for review and concurrence and to ensure all 

training requirements for the Contracting Officer Technical Representative (COTR) are 

completed within established timeframes. The SOARS guidelines are used by the 

committee to review contracts to ensure contract requirements and modifications, 

including extensions, are appropriate and consistent with federal acquisition 

requirements. The findings of the committee are submitted to the Medical Center 

Executive Board for review and concurrence. 

Recommendation 14. We recommended that the Oklahoma City VAMC Director take 

appropriate action to ensure the accuracy of reported PCMM data is in accordance with 

the PCMM Handbook. 

Concur 

Target date for completion: Complete 

VA OIG Office of Healthcare Inspections 40 
Springfield, Morehead City, Raleigh, Clarksville, Cookeville, Wichita Falls, and Klamath Falls 

The Wichita Falls CBOC panels were reviewed. Dually assigned patients were removed 

if Oklahoma City VAMC was not assigned as the parent facility. When Oklahoma City 

VAMC was assigned as the parent facility, the non-parent facility was notified to remove 

patients from their facility panels. Monthly monitoring of CBOC panels will be 

completed to ensure compliance. Findings during the OIG review indicate there were 

differences with Wichita Falls CBOC assigned patients being incorrectly coded to the 

parent facility (Oklahoma City VAMC) in PCMM. The report used to validate the 

assigned patients (Patient Aligned Care Teams-COMPASS) with the PCMM 

assignment was reviewed. Our findings indicate there is one provider that continues to 

be captured under the Oklahoma City VAMC report instead of the Wichita Fall CBOC. 

Although the provider was coded correctly in PCMM as a physician assistant to the 

Wichita Falls team, we identified the problem with the coding of his person class and 

have corrected that to indicate a Contractor/PA. 

VA OIG Office of Healthcare Inspections 41 
Springfield, Morehead City, Raleigh, Clarksville, Cookeville, Wichita Falls, and Klamath Falls 

Appendix I

VISN 20 Director Comments

Department of

Veterans Affairs Memorandum

Date: May 26, 2011 

From: Director, VISN 20 (10N20) 

Subject: CBOC Review: Klamath Falls, OR 

To: Director, Seattle Healthcare Inspections Division (54SE) 

Director, Management Review Services (VHA 10A4A4) 

1.	 Thank you for the opportunity to provide a status report on the draft 

findings from the Community Based Outpatient Clinic (CBOC) 

Review, Klamath Falls, Oregon. 

2.	 Attached please find the facility concurrences and responses to 

each of the findings from the review. 

3.	 If you have additional questions or need further information, please 

contact Susan Gilbert, Survey Coordinator, VISN 20 at (360) 567­

4678. 

VA OIG Office of Healthcare Inspections 42 
Springfield, Morehead City, Raleigh, Clarksville, Cookeville, Wichita Falls, and Klamath Falls 

Appendix J

Southern Oregon Rehabilitation Center and Clinics

Director Comments

Department of

Veterans Affairs Memorandum

Date: May 26, 2011 

From: Acting Director, Southern Oregon Rehabilitation Center and 

Clinics (692/00) 

Subject: CBOC Review: Klamath Falls, OR 

To: Director, VISN 20 (10N20) 

1.	 On behalf of the VA Community Based Outpatient Clinic (CBOC) in 

Klamath Falls, Oregon, I would like to express my appreciation to the 

Office of Inspector General (OIG) Survey Team for their professional 

and Comprehensive Assessment Program (CBOC) review conducted 

March 7-10, 2011. 

2.	 The findings from the report we have reviewed and provided 

responses addressing each recommendation. The responses include 

actions that are in progress and those that have already been 

implemented. 

3.	 We appreciate the opportunity for the review as a continuing process 

to improve the care we provide for our Veterans. 

VA OIG Office of Healthcare Inspections 43 
Springfield, Morehead City, Raleigh, Clarksville, Cookeville, Wichita Falls, and Klamath Falls 

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 15. We recommended that measurable performance data is 

maintained in all provider profiles to support physician reprivileging at the Klamath Falls 

CBOC. 

Concur 

Target date for completion: Process was completed and implemented April 1, 2011. 

Facility’s response: During the OIG visit the new process for OPPEs had been 

developed but not implemented. Subsequently the process has been fully implemented. 

Risk Management does 10% spot checks per quarter for Dental and Pharmacy Services 

and bi-annual spot checks for Medicine and Psychiatry which includes the Klamath Falls 

CBOC. OPPE is reviewed prior to re-privileging. 

Recommendation 16. We recommended that normal test results are consistently 

communicated to patients within the specified timeframe at the Klamath Falls CBOC. 

Concur 

Target date for completion: An Improvement Team is currently in progress. A system 

will be in place to report normal test results to patients who receive his/her care at the 

Klamath Falls (CBOC) by August 1, 2011 and the data collection and analyze [analysis] 

to be reported in the new fiscal year, starting Oct. 1, 2011. 

Facility’s response: A performance improvement work group consisting of stakeholders 

has been implemented to develop a means to communicate posted normal lab results 

within 14 days is extended to include normal results to the Klamath Falls CBOC. The 

processes this team develops will be implemented by August 1, 2011. In our facility 

quarterly medical record chart reviews will include audits to identify if these normal test 

results are consistently communicated and documented with the specified time frame. 

The data collected will be presented to Performance Enhancement Team (PET) 

quarterly beginning in the new fiscal year, October 1, 2011. 

VA OIG Office of Healthcare Inspections 44 
Springfield, Morehead City, Raleigh, Clarksville, Cookeville, Wichita Falls, and Klamath Falls 

Appendix K

OIG Contact and Staff Acknowledgments

Contact For more information about this report, please 

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

contact the 

Contributors Annette Acosta, RN 

Nancy Albaladejo, RN 

Bruce Barnes 

Shirley Carlile, BA 

Myra Conway, RN 

Lin Clegg, PhD 

Marnette Dhooghe, MS 

Nathan Fong, CPA 

Katharine Foster, RN 

Donna Giroux, RN 

Zhana Johnson, CPA 

Gayle Karamanos, PA 

Cathleen King, RN 

Daniel Kolb, PhD 

Linda DeLong, RN 

Anthony M. Leigh, CPA 

Sarah Lutter, RN, JD 

Claire McDonald, MPA 

Karen Moore, RN 

Roxanna Osegueda, MBA 

Mary Noel Rees, MPA 

Clarissa B. Reynolds, MBA 

Larry Ross, MS 

Natalie Sadow-Colon, MBA 

Thomas J. Seluzicki, CPA 

Lynn Sweeney, MD 

Ann Ver Linden, RN 

Susan Zarter, RN 

VA OIG Office of Healthcare Inspections 45 
Springfield, Morehead City, Raleigh, Clarksville, Cookeville, Wichita Falls, and Klamath Falls 

Appendix L

Report Distribution

VA Distribution

Office of the Secretary
 

Veterans Health Administration
 

Assistant Secretaries
 

General Counsel
 

Director, VISN 1 (10N1)
 

Director, Northampton VAMC (631/00)
 

Director, VISN 6 (10N6)
 

Director, Durham VAMC (558/00)
 

Director, VISN 9 (10N9)
 

Director, Tennessee Valley HCS (626/00)
 

Director, VISN 16 (10N16)
 

Director, Oklahoma City VAMC (635/00)
 

Director, VISN 20 (10N20)
 

Acting Director, Southern Oregon Rehabilitation Center and Clinics (692/00)
 

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: Lamar Alexander, Scott P. Brown, Richard Burr, Tom Coburn, Bob Corker, 

John Cornyn, Kay R. Hagan, Kay Bailey Hutchison, James M. Inhofe, John F. Kerry, 

Jeff Merkley, Ron Wyden 

U.S. House of Representatives: Diane Black, Marsha Blackburn, Walter B. Jones, 

James Lankford, Brad Miller, Richard E. Neal, Mac Thornberry, Greg Walden 

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

VA OIG Office of Healthcare Inspections 46