Department of Veterans Affairs 

Office of Inspector General 

Office of Healthcare Inspections
 

Report No. 11-01406-13 

Community Based Outpatient
 

Clinic Reviews
 

Gillette and Powell, WY
 

Pueblo, CO
 

Anaheim and Laguna Hills, CA
 

Escondido and Oceanside, CA
 

Lancaster and Sepulveda, CA 

November 2, 2011
 

Washington, DC 20420
 
Why We Did This Review 

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

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

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

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

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

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

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

Ambulatory and Primary Care Services to include CBOCs located throughout the 

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

care for currently enrolled users and to improve access opportunities within 

existing resources for eligible veterans not currently served. 

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

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

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

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

patient safety, and performance. 

To Report Suspected Wrongdoing in VA Programs and Operations 

Telephone: 1-800-488-8244 

E-Mail: vaoighotline@va.gov 

(Hotline Information: http://www.va.gov/oig/contacts/hotline.asp) 
Gillette, Powell, Pueblo, Anaheim, Laguna Hills, Escondido, Oceanside, Lancaster, and Sepulveda 

Glossary
 C&P 

CBOC 

CPRS 

CT 

DX & TX Plan 

ED 

EKG 

EOC 

FPPE 

FTE 

FY 

HCS 

IT 

JC 

LCSW 

MedMgt 

MH 

MHICM 

MRI 

MST 

NP 

OIG 

OPPE 

PA 

PCMM 

PCP 

PET 

PTSD 

Qtr 

TX 

VAMC 

VHA 

VISN 

credentialing and privileging 

community based outpatient clinic 

Computerized Patient Record System 

Computerized Tomography 

Diagnosis & Treatment Plan 

emergency department 

electrocardiogram 

environment of care 

Focused Professional Practice Evaluation 

full-time employee equivalents 

fiscal year 

Health Care System 

information technology 

Joint Commission 

Licensed Clinical Social Worker 

medication management 

mental health 

mental health intensive case management 

Magnetic Resonance Imaging 

military sexual trauma 

nurse practitioner 

Office of Inspector General 

Ongoing Professional Practice Evaluation 

physician assistant 

Primary Care Management Module 

primary care provider 

Positron Emission Tomography 

Post-Traumatic Stress Disorder 

quarter 

treatment 

VA Medical Center 

Veterans Health Administration 

Veterans Integrated Service Network 

VA OIG Office of Healthcare Inspections 
Gillette, Powell, Pueblo, Anaheim, Laguna Hills, Escondido, Oceanside, Lancaster, and Sepulveda 

Table of Contents
 

Page
 

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

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

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

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

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

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

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

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

Women’s Health...................................................................................................... 8
 

C&P ........................................................................................................................ 11
 

Skills Competency .................................................................................................. 12
 

Environment and Emergency Management............................................................ 13
 

PCMM..................................................................................................................... 16
 

CBOC Contract....................................................................................................... 17
 

Appendixes 

A. VISN 19 Director Comments ............................................................................. 21
 

B. Sheridan VAMC Director Comments................................................................. 22
 

C. VA Eastern Colorado HCS Director Comments ................................................ 25
 

D. VISN 22 Director Comments ............................................................................. 26
 

E. VA Long Beach HCS Director Comments ......................................................... 27
 

F. VA San Diego HCS Director Comments............................................................ 33
 

G. VA Greater Los Angeles HCS Director Comments............................................ 37
 

H. OIG Contact and Staff Acknowledgments ......................................................... 42
 

I. Report Distribution............................................................................................. 43
 

VA OIG Office of Healthcare Inspections 
Gillette, Powell, Pueblo, Anaheim, Laguna Hills, Escondido, Oceanside, Lancaster, and Sepulveda 

Executive Summary
 

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

July 25, 2011. We evaluated select activities to assess whether the CBOCs operated in 

a manner that provides veterans with consistent, safe, high-quality health care. Table 1 

lists the sites inspected. 

VISN Facility CBOC 

19 Sheridan VAMC 

Gillette, WY 

Powell, WY 

VA Eastern Colorado HCS Pueblo, CO 

22 VA Long Beach HCS Anaheim, CA 

Laguna Hills, CA 

VA San Diego HCS Escondido, CA 

Oceanside, CA 

VA Greater Los Angeles HCS Lancaster, CA 

Sepulveda, CA 

Table 1. Sites Inspected 

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

respective CBOC managers, should take appropriate actions to: 

Sheridan VAMC 

	 Establish a process to document justification in the medical record for the use of 

Short-Term Fee Basis care at the Gillette and Powell CBOCs. 

	 Ensure scopes of practice are facility-specific at the Powell CBOC. 

	 Maintain adequate competency data in all providers’ profiles and reflect sufficient 

discussion of the competency data in the Executive Committee of the Medical Staff 

meeting minutes. 

	 Monitor and collect measurable data for hand hygiene at the Gillette and Powell 

CBOCs. 

	 Ensure the PCMM Coordinator performs in accordance with VHA policy to reduce 

the number of veterans assigned to more than one PCP. 

	 Ensure the facility investigates revamping the monthly billing validation process by 

providing the list of VA patients seen at the clinic to the contractor that can be used 

as support for the monthly invoice. 

VA Eastern Colorado HCS 

	 We made no recommendations. 

VA OIG Office of Healthcare Inspections i 
Gillette, Powell, Pueblo, Anaheim, Laguna Hills, Escondido, Oceanside, Lancaster, and Sepulveda 

VA Long Beach HCS 

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

Laguna Hills CBOC can receive emergent MH care when necessary. 

	 Develop a local policy for Short-Term Fee Basis consults at the VA Long Beach 

HCS. 

	 Ensure that Short-Term Fee Basis reports for Laguna Hills CBOC patients are filed 

or scanned into the medical record. 

	 Establish a process to ensure that patients at the Anaheim and Laguna Hills CBOCs 

with normal mammograms are provided written notification of results within the 

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

	 Ensure that patients with abnormal mammography results at the Laguna Hills CBOC 

are notified by their provider within 14 calendar days and notification is documented 

in the medical record. 

	 Initiate FPPEs for all physicians who have been newly hired at the Laguna Hills 

CBOC. 

	 Maintain adequate competency data in all providers’ profiles at the Laguna Hills 

CBOC. 

	 Define who is responsible for competency validation and what the process is for 

selection of qualified personnel to assess and validate competencies at the Anaheim 

CBOC. 

	 Develop a competency policy for staff at the Laguna Hills CBOC that defines 

required core competencies, includes who is responsible for competency validation, 

describes the process for selecting qualified personnel to validate competencies, 

and denotes the actions taken when staff cannot demonstrate competency. 

	 Ensure competencies are assessed annually for staff members at the Anaheim 

CBOC in accordance with local policy. 

	 Ensure that the PCMM Coordinator performs in accordance with VHA policy to 

perform panel assignment after completion of the patient’s first appointment. 

	 Ensure that the PCMM Coordinator performs in accordance with VHA policy to 

reduce the number of veterans assigned to more than one PCP. 

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

requirements for payment. 

VA OIG Office of Healthcare Inspections ii 
Gillette, Powell, Pueblo, Anaheim, Laguna Hills, Escondido, Oceanside, Lancaster, and Sepulveda 

	 Ensure the Contracting Officer adds provisions to the contract that require 

reimbursement to the VA when a prepaid annual capitated rate for disenrolled 

patients and the remaining contract period is less than a year. 

VA San Diego HCS 

	 Develop a local policy for Short-Term Fee Basis consults at the VA San Diego HCS. 

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

patients are filed or scanned into the medical record. 

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

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

from the date made available to the ordering provider. 

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

	 Ensure that the MH front-desk staff at the Oceanside CBOC receive portable silent 

alarm call buttons. 

	 Install signage to clearly identify the location of fire extinguishers at the Oceanside 

CBOC. 

	 Ensure that the VHA Sharing Office takes appropriate steps to award a competitive 

long-term contract and requests that interim contracts comply with the provisions of 

VA Directive 1663. 

VA Greater Los Angeles HCS 

	 Grant privileges consistent with the services provided at the Lancaster and 

Sepulveda CBOCs. 

	 Improve access for disabled veterans at the Lancaster CBOC. 

	 Conduct fire drills annually at the Sepulveda CBOC. 

	 Conduct annual fire and life safety inspections at the Sepulveda CBOC. 

	 Ensure that two patient identifiers are used by staff when collecting blood samples at 

the Lancaster CBOC. 

	 Ensure that the PCMM Coordinator performs in accordance with VHA policy to 

reduce the number of veterans assigned to more than one PCP. 

	 Require that the Contracting Officer ensures there are performance incentive/penalty 

provisions in the contract, particularly those related to VHA quality of medical care 

standards. 

VA OIG Office of Healthcare Inspections iii 
Gillette, Powell, Pueblo, Anaheim, Laguna Hills, Escondido, Oceanside, Lancaster, and Sepulveda 

	 Require that the VHA Sharing Office takes appropriate steps to ensure that medical 

contracting is performed in accordance with applicable laws, regulations, and 

policies, and that interim contracts are approved in advance by VHA’s Medical 

Sharing Office as required by VA Directive 1663. 

	 Ensure that the VISN Director, Contracting Officer, and Facility Director take the 

steps necessary to award a long-term contract to obtain required services for the 

Lancaster CBOC. 

	 Require that the facility has a complete copy of all applicable contracts and ensures 

that all invoices are appropriately validated so VA resources are accurately 

expended. 

	 Ensure that the Contracting Officer confers with Regional Counsel to determine the 

amount and collectability of the overpayments. 

Comments 

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

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

pages 21–41 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 iv 
Gillette, Powell, Pueblo, Anaheim, Laguna Hills, Escondido, Oceanside, Lancaster, and Sepulveda 

Objectives and Scope 

Objectives. The purposes of this review are to: 

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

the management of MH emergencies.1 

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

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

quality and timeliness of patient care in CBOCs. 

 Determine whether CBOCs comply with selected VHA requirements regarding the 

provision of mammography services for women veterans. 

 Determine whether CBOC providers are appropriately credentialed and privileged in 

accordance with VHA policy.2 

 Determine whether CBOCs have well-developed competency assessment and 

validation programs in place for skill specific competencies. 

 Determine whether CBOCs are in compliance with standards of operations 

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

planning.3 

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

accordance with contract terms and conditions. 

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

compliance with VHA policy.4 

Scope. The topics discussed in this report include: 

 MH Continuity of Care 

 Short-Term Fee Basis Care 

 Women’s Health 

 C&P 

 Skills Competency 

 Environment and Emergency Management 

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

VA OIG Office of Healthcare Inspections 1 
Gillette, Powell, Pueblo, Anaheim, Laguna Hills, Escondido, Oceanside, Lancaster, and Sepulveda 

 PCMM 

 Contracts 

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

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

Informational Report Community Based Outpatient Clinics Cyclical Report FY 2011, 

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

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

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

VA OIG Office of Healthcare Inspections 2 
Gillette, Powell, Pueblo, Anaheim, Laguna Hills, Escondido, Oceanside, Lancaster, and Sepulveda 

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

CBOCs and specific characteristics. 

Pueblo Gillette Powell Anaheim Laguna 

Hills 

Escondido Oceanside Lancaster Sepulveda 

VISN 19 19 19 22 22 22 22 22 22 

Parent Facility VA Eastern 

Colorado HCS 

Sheridan 

VAMC 

Sheridan 

VAMC 

VA Long 

Beach HCS 

VA Long 

Beach HCS 

VA San 

Diego HCS 

VA San 

Diego HCS 

Greater LA 

HCS 

Greater LA 

HCS 

Type of CBOC VA VA Contract VA Contract Contract VA Contract VA 

Number of 

Uniques,5 FY 

2010 

18,611 1,015 1,296 3,373 4,146 5,142 10,645 3,613 30,390 

Number of 

Visits, FY 2010 

98,136 3,713 4,186 11,478 11,500 17,567 42,685 11,501 263,018 

CBOC Size6 Very Large Small Small Mid-Size Mid-Size Large Very Large Mid-Size Very Large 

Locality Urban Rural Highly Rural Urban Urban Urban Urban Urban Urban 

FTE PCP 5.95 0.91 1 2.90 3 5.20 7.60 2 14.34 

FTE MH 11.5 0.6 0.5 1.6 2.8 2.0 2.0 0 29.4 

Types of 

Providers 

PCP 

NP 

Psychiatrist 

LCSW 

PCP 

NP 

Psychiatrist 

PCP 

PA 

LCSW 

PCP 

NP 

Psychiatrist 

Psychologist 

LCSW 

PCP 

NP 

Psychiatrist 

Psychologist 

PCP 

NP 

Psychiatrist 

Psychologist 

LCSW 

PCP 

Psychiatrist 

Psychologist 

LCSW 

PCP 

NP 

PA 

PCP 

NP 

PA 

Psychiatrist 

Psychologist 

LCSW 

Specialty Care 

Services Onsite 

Yes Yes No Yes No Yes Yes Yes Yes 

Tele-Health 

Services 

Tele-Medicine 

Tele-Retinal 

Tele-Medicine 

Tele-Retinal 

Tele-Medicine 

Tele-Retinal 

Tele-Medicine 

Tele-Retinal 

Tele-Retinal None None Patient 

Education 

Tele-Medicine 

Tele-Retinal 

Ancillary 

Services 

Provided Onsite 

Laboratory 

Pharmacy 

PT/OT 

Radiology 

EKG 

Laboratory 

EKG 

Spirometry 

Laboratory 

EKG 

Spirometry 

Laboratory 

EKG 

Laboratory 

EKG 

Laboratory 

EKG 

Laboratory 

PT/OT 

Radiology 

EKG 

Prosthetics 

CPAP 

Laboratory 

Radiology 

EKG 

Laboratory 

Pharmacy 

PT/OT 

Radiology 

EKG 

EMG, ECHO 

Table 2. CBOC Characteristics 

5 http://vaww.pssg.med.va.gov 

6 Based on the number of unique patients seen as defined by the VHA Handbook 1160.01, the size of the CBOC facility is categorized as very large (> 10,000), large 

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

VA OIG Office of Healthcare Inspections 3 
Gillette, Powell, Pueblo, Anaheim, Laguna Hills, Escondido, Oceanside, Lancaster, and Sepulveda 

Results and Recommendations
 

MH Continuity of Care 

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

delivery of MH care in associated CBOCs.7 Also, there must be methods and 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

well as tele-mental health. 

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

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

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

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

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

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

psychosocial rehabilitation services including family education, skills training, and peer 

support; compensated work therapy and supported employment; PTSD teams or 

specialists; MST special clinics; homeless programs; and specialty substance abuse 

treatment services. Table 3 displays the MH Characteristics for each CBOC reviewed. 

7 VHA Handbook 1160.01. 

VA OIG Office of Healthcare Inspections 4 
Gillette, Powell, Pueblo, Anaheim, Laguna Hills, Escondido, Oceanside, Lancaster, and Sepulveda 

Mental Health CBOC Characteristics 

Pueblo Gillette Powell Anaheim Laguna Hills Escondido Oceanside Lancaster Sepulveda 

Provides 

MH 

Services 

Yes Yes Yes Yes Yes Yes Yes No Yes 

Number of 

MH 

Uniques, 

FY 2010 

2,702 80 119 646 1,051 829 2,108 1218 6,052 

Number of 

MH Visits 

23,457 329 611 1,641 2,258 4,155 10,559 4319 83,168 

General MH 

Services 

Dx & TX Plan 

MedMgt 

Psychotherapy 

PTSD 

MST 

Dx & TX Plan 

MedMgt 

Psychotherapy 

PTSD 

MST 

PTSD 

MST 

Dx & TX Plan 

MedMgt 

Psychotherapy 

PTSD 

MST 

Dx & TX Plan 

MedMgt 

Psychotherapy 

PTSD 

MST 

Dx & TX Plan 

MedMgt 

Psychotherapy 

PTSD 

MST 

Dx & TX Plan 

MedMgt 

Psychotherapy 

PTSD 

NA Dx & TX Plan 

MedMgt 

Psychotherapy 

PTSD 

MST 

Specialty 

MH 

Services 

Consult & TX 

Psychotherapy 

MHICM 

Compensated 

Work Therapy 

PTSD 

MST 

Homeless 

Prgm 

Specialty 

Substance 

Abuse TX 

Consult & TX None Consult & TX 

Social Skills 

Specialty 

Substance 

Abuse TX 

Consult & TX 

Psychotherapy 

Consult & TX 

Psychotherapy 

Social Skills 

Peer Support 

PTSD 

Homeless 

Prgm 

Specialty 

Substance 

Abuse TX 

Consult & TX 

Psychotherapy 

MHICM 

Peer Support 

PTSD 

Homeless 

Prgm 

Specialty 

Substance 

Abuse TX 

NA Consult & TX 

Psychotherapy 

MHICM 

Psychosocial 

Rehab 

Social Skills 

Peer Support 

Compensated 

Work Therapy 

PTSD 

MST 

Homeless 

Prgm 

Specialty 

Substance 

Abuse TX 

Tele-Mental 

Health 

Yes Yes Yes No No Yes Yes Yes Yes 

MH 

Referrals 

Another VA 

Facility 

Another VA 

Facility 

Fee-Basis 

Another 

VA Facility 

Another VA 

Facility 

Another VA 

Facility 

Another VA 

Facility 

Another VA 

Facility 

Fee-Basis 

Another VA 

Facility 

Another VA 

Facility 

Table 3. MH Characteristics for CBOCs 

8 Mental Health Services provided through Tele-Mental Health Services. 

9 Same as above. 

VA OIG Office of Healthcare Inspections 5 
Gillette, Powell, Pueblo, Anaheim, Laguna Hills, Escondido, Oceanside, Lancaster, and Sepulveda 

Emergency Plan 

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

care at CBOCs.10 All CBOCs and facilities without an ED or 24/7 urgent care must have 

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

Table 4 shows the areas reviewed for this topic. 

Noncompliant Areas Reviewed 

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

accessible VA or community-based ED where veterans are 

directed to seek emergent care when necessary. 

The facility has developed contracts, sharing agreements, or 

other appropriate arrangements with the external organization for 

sharing information. 

The facility has developed financial arrangements for payment for 

authorized emergency services and necessary subsequent care. 

There is documentation in CPRS of the ED visit. 

There are recommendations documented for follow-up care in 

accordance with local policy. 

The recommendations were implemented and documented in the 

medical records in accordance with local policy. 

Table 4. MH Continuity of Care 

VISN 22, VA Long Beach HCS – Laguna Hills 

Emergency Plan. Although the Laguna Hills CBOC had a plan identified in their local 

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

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

plan did not identify a VA or community-based ED where veterans are directed to seek 

care. 

Short-Term Fee Basis Care 

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

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

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

treatment economically because of their geographical inaccessibility. Fee Basis care 

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

transportation. 

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

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

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

improvement. Details regarding the findings follow the table. 

10 VHA Handbook 1160.01. 

VA OIG Office of Healthcare Inspections 6 
Gillette, Powell, Pueblo, Anaheim, Laguna Hills, Escondido, Oceanside, Lancaster, and Sepulveda 

Noncompliant Areas Reviewed 

Anaheim 

Laguna Hills 

Escondido 

Oceanside 

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

and services purchased by authority that describe the request, 

approval, and authorization process for such services.11 

Gillette 

Powell 

The provider documented a justification for using Fee Basis status 

in lieu of providing staff treatment as required by VHA policy.12 

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

the date the consult was initiated. 

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

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

Medical Administration Services, or an authorized designee.13 

Patients were notified of consult approvals in writing as required by 

VHA policy.14 

Laguna Hills 

Escondido 

A copy of the imaging report is in CPRS according to VHA policy.15 

There is evidence the ordering provider or surrogate practitioner 

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

results are available to the ordering practitioner. 

Escondido There is evidence the ordering provider or other licensed healthcare 

staff member informed the patient about the report within 14 days 

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

practitioner.16 

Table 5. Short-Term Fee Basis 

VISN 19, Sheridan VAMC – Gillette and Powell 

There were 25 patients who received services through a Short-Term Fee Basis consult 

at the Gillette CBOC and 46 patients at the Powell CBOC. 

Fee Basis Justification. The Sheridan VAMC did not require providers at the Gillette 

and Powell CBOCs to document justifications for Fee Basis procedures in CPRS. 

CBOC providers order procedures in the radiology scheduling package. The Radiology 

Department preauthorizes the procedure in the Fee package, and the Fee Basis 

manager approves all Fee Basis procedures. 

11 VHA Handbook 1160.01.
 11 VHA Chief Business Office Policy 1601F, Fee Services, http://vaww1.va.gov/cbo/apps/policyguides/index.asp
 11 VHA Handbook 1907.01, Health Information Management and Health Records, August 25, 2006.
 11 VHA Manual M-1, PART I, Chapter 18, “Outpatient Care – Fee,” July 20, 1995.
 12 VHA Handbook 1907.01.
 13 VHA Chief Business Office Policy 1601F.
 14 VHA Manual M-1, PART I, Chapter 18.
 15 VHA Handbook 1907.01.
 16 VHA Directive 2009-019, Ordering and Reporting Test Results, March 24, 2009.
 

VA OIG Office of Healthcare Inspections 7 
Gillette, Powell, Pueblo, Anaheim, Laguna Hills, Escondido, Oceanside, Lancaster, and Sepulveda 

VISN 22, VA Long Beach HCS – Anaheim and Laguna Hills 

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

at the Laguna Hills CBOC and one patient at the Anaheim CBOC. 

Policy. The VA Long Beach HCS did not have a local policy for Short-Term Fee Basis 

consults. 

Medical Record. At the Laguna Hills CBOC, we did not find a copy of the Short-Term 

Fee Basis imaging report in one of the two patient medical records reviewed. VHA 

policy requires copies of reports be filed or scanned in the medical record.17 

VISN 22, VA San Diego HCS – Escondido and Oceanside 

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

consult at the Escondido CBOC. No patients at the Oceanside CBOC met the criteria 

for this review. 

Policy. The VA San Diego HCS did not have a local policy for Short-Term Fee Basis 

consults. 

Medical Record. At the Escondido CBOC, we did not find a copy of the Short-Term Fee 

Basis imaging report in one of three patient medical records reviewed. 

Communication of Results. There was no evidence in the medical record that two 

patients at the Escondido CBOC were informed about the results within 14 calendar 

days. 

Women’s Health Review 

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

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

conditions, that is comparable to care provided for male veterans.18 All eligible and 

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

access to all necessary services as clinically indicated. 

Quality of Care Measures19 

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

with approximately 207,000 new cases reported each year.20 Timely screening, 

17 VHA Handbook 1907.01
 18 VHA Handbook 1330.01, Healthcare Services for Women Veterans, May 21, 2010.
 19 Parent facility scores were obtained from http://vaww.pdw.med.va.gov/MeasureMaster/MMReport.asp Note:
 

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

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

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

VA OIG Office of Healthcare Inspections 8 
Gillette, Powell, Pueblo, Anaheim, Laguna Hills, Escondido, Oceanside, Lancaster, and Sepulveda 

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

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

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

20–30 percent among women age 40 and older. 

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

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

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

respective CBOCs’ scores. 

Measure 

Meets 

Target Facility 

Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 

(%) 

Mammography, 

50-69 years old 77% 666 Sheridan VAMC 20 24 90 

666GE Gillette 14 16 88 

666GD Powell 19 24 79 

554 VA Eastern CO HCS 30 35 88 

554GD Pueblo 29 30 97 

600 VA Long Beach HCS 18 21 94 

600GA Anaheim 19 19 100 

600GE Laguna Hills 6 7 86 

664 VA San Diego HCS 17 21 79 

664GD Escondido 23 28 83 

664GB Oceanside 28 30 93 

VA Greater Los Angeles HCS 27 30 90 

691GG Lancaster 23 24 96 

691A4 Sepulveda 27 28 96 

Table 6. Mammography Screening FY 2011 

Mammography Management 

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

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

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

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

veterans seeking ongoing health care.21 Therefore, regardless of the number of women 

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

comprehensive primary care to women veterans and all necessary gender specific 

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

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

Details regarding the findings follow the table. 

21 VHA Handbook 1330.01. 

VA OIG Office of Healthcare Inspections 9 
Gillette, Powell, Pueblo, Anaheim, Laguna Hills, Escondido, Oceanside, Lancaster, and Sepulveda 

Noncompliant Areas Reviewed 

Patients are referred to mammography facilities that have current 

Food and Drug Administration or State-approved certifications. 

Mammogram results are documented using the American College 

of Radiology’s BI-RADS code categories.22 

The ordering VHA provider or surrogate was notified of abnormal or 

critical results within a defined timeframe. 

Laguna Hills Patients with abnormal or critical results are notified within a defined 

timeframe. 

Anaheim 

Laguna Hills 

Patients receive written notice of normal mammogram results, and 

the notifications are documented in the patients’ medical record as 

required by VHA policy.23 

The facility has an established process for tracking results from 

mammograms performed off-site. 

Fee Basis mammography reports are scanned into CPRS. 

All screening and diagnostic mammograms were initiated via an 

order placed into the Veterans Health Information Systems and 

Technology Architecture Radiology package.24 

Each CBOC has an appointed Women’s Health Liaison. 

There is evidence that the Women’s Health Liaison collaborates 

with the parent facility’s Women Veterans Program Manager on 

women’s health issues. 

Table 7. Mammography 

VISN 22, VA Long Beach HCS – Anaheim and Laguna Hills 

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

patients at the Anaheim CBOC who had normal mammography results and determined 

that 6 of 11 patients did not have documentation in their medical records of notification 

within the required timeframe. At the Laguna Hills CBOC, three of four patient medical 

records did not have the required documentation. 

Communication of Abnormal Results. We found that the patient with an abnormal 

mammogram at the Laguna Hills CBOC did not have documented evidence in their 

medical record that they were informed about the results within 14 calendar days. VHA 

policy requires the provider communicates the results to patients no later than 14 

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

practitioner. Documentation of the notification must be entered into the medical 

record.25 

22 The American College of Radiology’s Breast Imaging Reporting and Database System is a quality assurance
 

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

23 VHA Handbook 1330.01.
 24 VHA Handbook 1330.01.
 25 VHA Directive 2009-019.
 

VA OIG Office of Healthcare Inspections 10 
Gillette, Powell, Pueblo, Anaheim, Laguna Hills, Escondido, Oceanside, Lancaster, and Sepulveda 

C&P 

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

ensure that providers complied with applicable requirements as defined by VHA 

policy.26 We reviewed nurse personnel files to ensure licensure and education were 

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

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

Noncompliant Areas Reviewed 

There was evidence of primary source verification for each 

provider’s license. 

Each provider’s license was unrestricted. 

There were two efforts made to obtain verification of clinical 

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

new providers. 

FPPEs for new providers outlined the criteria to be monitored. 

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

There was evidence that the provider was educated about FPPE 

prior to its initiation. 

FPPE results were reported to the medical staff’s Executive 

Committee. 

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

developed. 

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

Committee list documents reviewed and the rationale for 

conclusions reached for granting licensed independent practitioner 

privileges. 

Powell 

Lancaster 

Sepulveda 

Privileges granted to providers are facility, service, and provider 

specific.27 

Powell 

Laguna Hills 

The determination to continue current privileges are based in part 

on results of OPPE activities. 

Laguna Hills The OPPE and reappraisal process included consideration of such 

factors as clinical pertinence reviews and/or performance measure 

compliance. 

Relevant provider-specific data was compared to aggregated data 

of other providers holding the same or comparable privileges. 

Scopes of practice are facility specific. 

There is documentation that the nurses’ licenses were verified. 

There is evidence that the nurses’ education was verified. 

Table 8. C&P 

26 VHA Handbook 1100.19. 27 VHA Handbook 1100.19. 

VA OIG Office of Healthcare Inspections 11 
Gillette, Powell, Pueblo, Anaheim, Laguna Hills, Escondido, Oceanside, Lancaster, and Sepulveda 

VISN 19, Sheridan VAMC – Powell 

Clinical Privileges. The Professional Standards Board granted clinical privileges for 

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

privileges that included lumbar puncture and admitting privileges. 

OPPE. One of four licensed independent practitioner profiles reviewed at the Powell 

CBOC did not have sufficient evidence of data for the previous two 6-month OPPE 

periods. Also, the Executive Committee of the Medical Staff meeting minutes did not 

reflect adequate discussion of the provider’s data prior to reprivileging. 

VISN 22, VA Long Beach HCS – Laguna Hills 

FPPE. A newly hired psychiatrist at the Laguna Hills CBOC did not have an FPPE 

implemented. 

OPPE. Two of the three providers at the Laguna Hills CBOC did not have 

documentation of clinical pertinence reviews and/or performance measure compliance. 

VISN 22, VA Greater Los Angeles HCS – Lancaster and Sepulveda 

Clinical Privileges. We found that the Professional Standards Board granted clinical 

privileges for procedures that were not performed at the Lancaster and Sepulveda 

CBOCs. The providers were granted Internal Medicine core privileges, which included 

lumbar punctures, thoracentesis, paracentesis, intubation, and venous cutdowns. As of 

September 2010, the facility modified the privileges form and excluded procedures not 

performed in the outpatient setting; however, the new form is implemented when 

providers are re-privileged. Therefore, some providers continue to practice under the 

Internal Medicine core privileges. 

Skills Competency 

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

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

for this topic. 

Noncompliant Areas Reviewed 

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

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

Anaheim 

Laguna Hills 

The policy defines who is responsible for competency validation and 

what the process is for selection of qualified personnel to assess 

and validate competence. 

Laguna Hills The CBOC has a policy or process describing actions taken when 

staff cannot demonstrate competency. 

The facility has identified skill competencies for the CBOC. 

VA OIG Office of Healthcare Inspections 12 
Gillette, Powell, Pueblo, Anaheim, Laguna Hills, Escondido, Oceanside, Lancaster, and Sepulveda 

Noncompliant Areas Reviewed (continued) 

Staff competency was initially assessed and documented as a part 

of the CBOC orientation. 

Anaheim Patient care staff identified skill competencies were validated and 

documented. 

Table 9. Skills Competency 

VISN 22, VA Long Beach HCS – Anaheim and Laguna Hills 

Policy. The Anaheim CBOC competency policy did not define who is responsible for 

competency validation or describe the process for selection of qualified personnel to 

access and validate competencies. The Laguna Hills CBOC did not have a competency 

policy. 

Core Competencies. We reviewed the competency folders of six staff members at the 

Anaheim CBOC and found that at least one core competency for each staff member 

was not assessed annually. Local policy requires annual assessment of competencies. 

Environment and Emergency Management 

EOC 

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

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

The facilities identified as noncompliant needed improvement. Details regarding the 

findings follow the table. 

Noncompliant Areas Reviewed 

There is handicap parking, which meets the ADA requirements. 

The CBOC entrance ramps meet ADA requirements. 

Lancaster The entrance door to the CBOC meets ADA requirements. 

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

good repair, walls without holes, etc.). 

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

The patient care area is safe. 

Medical equipment is checked routinely (biomedicine tags when 

applicable). 

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

areas as identified by the vulnerability risk assessment. 

Escondido Privacy is maintained. 

IT security rules are adhered to. 

Patients’ personally identifiable information is secured and 

protected. 

There is alcohol hand wash or a soap dispenser and sink 

available in each examination room. 

The sharps containers are less than 3⁄4 full. 

VA OIG Office of Healthcare Inspections 13 
Gillette, Powell, Pueblo, Anaheim, Laguna Hills, Escondido, Oceanside, Lancaster, and Sepulveda 

Noncompliant Areas Reviewed (continued) 

Sepulveda There is evidence of an annual fire and safety inspection. 

Sepulveda There is evidence of fire drills occurring at least annually. 

Oceanside Fire extinguishers are easily identifiable. 

Gillette 

Powell 

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

Lancaster Staff use two patient identifiers for blood drawing procedures. 

The CBOC is included in facility-wide EOC activities. 

Table 10. EOC 

VISN 19, Sheridan VAMC – Gillette and Powell 

Hand Hygiene. The Powell CBOC had not initiated hand hygiene monitors or collected 

data prior to February 2011. The Gillette CBOC stopped monitoring hand hygiene in 

November 2010. The Centers for Disease Control and Prevention recommend that 

healthcare facilities develop a comprehensive Infection Control program with a hand 

hygiene component, which includes monitors, data analysis, and provider feedback. 

VISN 22, VA San Diego HCS – Escondido and Oceanside 

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

process at the Escondido CBOC. Patients communicate with staff through a window 

located in the waiting area. Patients are asked to provide, at a minimum, their name 

and the last four digits of their social security number. We found a sign instructing 

patients and visitors to protect patient privacy at the check-in counter; however, staff did 

not ensure the zone of privacy was maintained. Additionally, staff verbalized a process 

of providing paper and a pen to patients to provide their personally identifiable 

information; however, this process was intermittently utilized. 

Fire Extinguishers. The Oceanside CBOC had no signage identifying the location of fire 

extinguishers. All fire extinguishers were recessed in the wall and obscured from view. 

According to National Fire Protection Association standards, fire extinguishers shall not 

be obstructed or obscured from view.28 

Panic Alarms. A risk assessment completed on March 16, 2011, at the Oceanside 

CBOC indicated that MH clinic operations make staff susceptible to violence in the 

workplace and identified that portable silent alarm call buttons had been distributed to 

staff. During our on-site visit, we identified front-desk staff in the MH clinic did not have 

panic alarms. The staff indicated that if they felt threatened and needed assistance, 

they would call for help and try to leave the room. 

28 National Fire Protection Association, Standard for Portable Fire Extinguishers, 10 6.1.3.3.1. 

VA OIG Office of Healthcare Inspections 14 
Gillette, Powell, Pueblo, Anaheim, Laguna Hills, Escondido, Oceanside, Lancaster, and Sepulveda 

VISN 22, VA Greater Los Angeles HCS – Sepulveda and Lancaster 

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

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

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

to operate.29 

Fire Drills. We did not find evidence of an annual fire drill for 2010 at Building 10, which 

houses the MH and Dental Clinic, at the Sepulveda CBOC. The JC requires that fire 

response planning identify the specific roles of those who work within the organization, 

including when and how to sound fire alarms, contain smoke and fire, use a fire 

extinguisher, and evacuate to areas of refuge.30 

Life Safety. We did not find evidence of an annual fire and life safety inspection at the 

Sepulveda CBOC for 2010 or 2011. Although the VISN conducts Annual Workplace 

Evaluations of the Sepulveda CBOC, the Annual Workplace Evaluation does not 

contain all elements of the fire and life safety inspection. VHA policy requires annual 

inspection of facilities for fire and life safety.31 

Patient identification. The Lancaster CBOC did not use two patient identifiers for blood 

drawing procedures. Two patient identifiers help to ensure that the procedure is 

performed for the correct patient.32 

Emergency Management 

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

defining how medical emergencies, including MH, are handled.33 Table 11 shows the 

areas reviewed for this topic. 

Noncompliant Areas Reviewed 

There is a local medical emergency management plan for this 

CBOC. 

The staff can articulate the procedural steps of the medical 

emergency plan. 

The CBOC clinical staff are trained in cardiopulmonary resuscitation 

with the use of an automated external defibrillator. 

The CBOC has an automated external defibrillator onsite for cardiac 

emergencies. 

29 Americans with Disabilities Act.
 30 Joint Commission Standard EC 02.03.01.
 31 VHA Center for Engineering & Occupational Safety and Health, Fire Safety Guide Book, Updated July 2009.
 32 Joint Commission Standard NPSG 01.01.01.
 33 VHA Handbook 1006.1.
 

VA OIG Office of Healthcare Inspections 15 
 

Gillette, Powell, Pueblo, Anaheim, Laguna Hills, Escondido, Oceanside, Lancaster, and Sepulveda 

Noncompliant Areas Reviewed 

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

The staff can articulate the procedural steps of the MH emergency 

plan. 

Table 11. Emergency Management 

All CBOCs were compliant with the topic areas; therefore, we made no 

recommendations. 

PCMM 

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

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

for ensuring that the information in the PCMM database is accurate and current.34 

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

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

Noncompliant Areas Reviewed 

Anaheim 

Laguna Hills 

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

prior to being seen for their first appointment. 

Gillette 

Powell 

Laguna Hills 

Lancaster 

Sepulveda 

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

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

facility. 

Patients are identified for removal from the PCMM panel on a 

monthly basis (at a minimum). 

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

patients for a full-time PCP. 

PCPs have been kept current in PCMM 

The number of patients invoiced is comparable to the total number 

of patients assigned to the PCP panels. 

Table 12. PCMM 

VISN 19, Sheridan VAMC ─ Gillette and Powell 

Confirmation of Panel Assignment. The Sheridan VAMC had approximately 

10,900 active patients, with 1,457 and 1,064 being assigned to the Powell and 

Gillette CBOCs, respectively. There were 99 patients (7 percent of the panel) 

assigned to a Powell PCP and 121 (11 percent of the panel) assigned to a Gillette 

PCP in PCMM that were also assigned to an additional PCP at other facilities 

without dual assignment approval. Patients with two or more PCPs assigned inflate 

34 VHA Handbook 1101.02, Primary Care Management Module, April 21, 2009. 

VA OIG Office of Healthcare Inspections 16 
 

 

Gillette, Powell, Pueblo, Anaheim, Laguna Hills, Escondido, Oceanside, Lancaster, and Sepulveda 

primary care panel sizes and could lead to increased medical care costs for 

contracted care. 

VISN 22, VA Long Beach HCS ─ Anaheim and Laguna Hills 

Panel Assignment Prior to First Appointment. Primary care panel assignments at the 

Anaheim and Laguna Hills CBOCs are not performed in accordance with VHA policy. 

Enrollment should be performed when the patient completes the first appointment, not 

when the patient schedules an appointment. 

Confirmation of Panel Assignment. The VA Long Beach HCS had approximately 

41,300 active patients, with 3,315 being assigned to the Laguna Hills CBOC. There 

were 242 patients (7 percent of the panel) assigned to a Laguna Hills PCP in PCMM 

that were also assigned to an additional PCP at other facilities without dual 

assignment approval. Patients with two or more PCPs assigned inflate primary care 

panel sizes and could lead to increased medical care costs for contracted care. 

VISN 22, VA Greater Los Angeles HCS ─ Lancaster and Sepulveda 

Confirmation of Panel Assignment. The VA Greater Los Angeles HCS had 

approximately 76,600 active patients, with 14,871 and 3,820 being assigned to the 

Sepulveda and Lancaster CBOCs, respectively. There were 799 patients (5 percent 

of the panel) assigned to a Sepulveda PCP and 189 (5 percent of the panel) 

assigned to a Lancaster PCP in PCMM that were also assigned to an additional PCP 

at other facilities without dual assignment approval. Patients with two or more PCPs 

assigned inflate primary care panel sizes and could lead to increased medical care 

costs for contracted care. 

CBOC Contract 

We conducted reviews of contracted primary care at the Powell, Laguna Hills, 

Escondido, and Lancaster CBOCs to evaluate the effectiveness of VHA oversight and 

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

services. Contracted MH services are provided at the Laguna Hills CBOC, and VA staff 

provides tele-mental health services at the Lancaster and Powell CBOCs. Each CBOC 

engagement included: 1) a review of the contract, 2) analysis of patient care encounter 

data, 3) corroboration of information with VHA data sources, 4) site visits, and 5) 

interviews with VHA and contractor staff. Our review focused on documents and 

records for 1st Qtr, FY 2011. 

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

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

VA OIG Office of Healthcare Inspections 17 
Gillette, Powell, Pueblo, Anaheim, Laguna Hills, Escondido, Oceanside, Lancaster, and Sepulveda 

Noncompliant Areas Reviewed 

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

Laguna Hills a. Requirements for payment. 

b. Rate and frequency of payment. 

c. Invoice format. 

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

e. Billing the patient or any other third party. 

Powell 

Escondido 

Lancaster 

(2) Technical review of contract modifications and extensions. 

Lancaster (3) Invoice validation process. 

(4) The Contracting Officer’s Technical Representative 

designation and training. 

Lancaster (5) Contractor oversight provided by the Contracting Officer’s 

Technical Representative. 

(6) Timely access to care. 

Table 13. Review of PC and MH Contract Compliance 

VISN 19, Sheridan VAMC – Powell 

Technical Review. The contract does not clearly define the requirements for payment. 

The contract required that each patient have an annual vesting office visit. The facility 

allowed for a more extensive vesting codes list than what was defined as a vesting visit 

in the contract. This caused confusion in how many patients met the criteria for 

payment. 

The current invoice validation process requires the facility to reconcile Sheridan VAMC’s 

master patient list against the Contractor’s master patient list. The Contractor’s list is 

provided in the form of a paper printout, which can contain over 40 pages 

and 1,200 patient names. The process of performing a manual review of the 

contractor’s list is very timely and is susceptible to error. This process places the risk 

on the VA to ensure the accuracy of the invoice. 

VISN 22, VA Long Beach HCS – Laguna Hills 

Requirements for Payment. The contract was not clear regarding the requirements for 

payment. The contract required the prepayment of an annual capitated rate per patient; 

however, the contract included phrases such as “an annual visit during the term of the 

contract may be required” and “if the local facility determines that the patient must be 

seen annually.” These phrases caused confusion in determining whether an annual 

visit was required for payment. The contractor prepared the invoicing based on the 

annual requirement; therefore, we found no discrepancies in the payment amounts. 

The contract does not have a provision for the VA to be reimbursed for months paid in 

advance when a patient is disenrolled from the clinic for any reason, such as transfer or 

VA OIG Office of Healthcare Inspections 18 
Gillette, Powell, Pueblo, Anaheim, Laguna Hills, Escondido, Oceanside, Lancaster, and Sepulveda 

death. The contract should also have a provision that pays a prorated amount as the 

end of the contract period approaches. Inclusion of these provisions should be 

mandatory if a prepaid annual capitated rate is used, which would save the VA a 

significant amount of resources. 

VISN 22, VA San Diego HCS – Escondido 

Technical Review. The contract was awarded on April 21, 2010, for a period of 

6 months beginning on May 5, 2010, with an option to extend another 6 months. It was 

extended for the additional 6 months to cover a 1-year period. Our review found that 

this was the second interim contract issued by the facility since the long-term contract 

that was awarded competitively in October 2006, and expired in 2009. When the 

interim contract expired on or about April 30, 2011, another interim contract was 

issued. Although the facility issued a solicitation for a new contract on April 18, 2011, a 

new contract was not awarded and we have been advised that another interim contract 

would be issued. With the exception of the most recent interim contract, records show 

that approvals for the interim contracts were not by the VHA Sharing Office, as required 

by VA Directive 1663.35 Approval for the interim contract effective May 1, 2011, was 

made by the Director of the VA San Diego HCS and approval for the interim contract 

awarded in 2009 was by the Network Director. The documentation shows that the 

interims were necessary due to lack of acquisition planning. 

VISN 22, VA Greater Los Angeles HCS – Lancaster 

Performance Measures. The contract does not contain any penalties if the contracted 

medical care does not meet VHA standards. The facility was monitoring quality of care 

performance measures but had no means to enforce VHA standards, short of 

terminating the contract. 

Invoice Validation Process. The facility did not have an invoice validation process 

during the 1st Qtr, FY 2011 but has subsequently initiated a manual validation process 

to manage more than 3,500 patients invoiced each month. The facility paid the invoice 

without the required supporting documentation and did not validate the number of 

qualifying enrollees. We found that the VA overpaid by over $12,000 each month over 

at least a 6-month period. 

Technical Review. The VA is paying for services under a contract that expired 

June 30, 2010. The contract does not state that it was an interim contract, but that 

appears to be the case. The contract was awarded on April 1, 2010, for a period of 

3 months with no option to extend. However, the contract was inappropriately extended 

through July 31, 2011, citing FAR clause 52.217-9, Option to Extend the Term of the 

Contract, as the authority that was not included in the contract. During the time of our 

site visit, the new contract still had not been awarded. 

35 VA Directive 1663, Health Care Resources Contracting – Buying, August 10, 2006. 

VA OIG Office of Healthcare Inspections 19 
Gillette, Powell, Pueblo, Anaheim, Laguna Hills, Escondido, Oceanside, Lancaster, and Sepulveda 

The Contracting Officer did not obtain VHA Sharing Office approval, which is required 

for interim contracts under VA Directive 1663. Records in the Electronic Contract 

Management System show that the last competitive contract expired in 2007. Although 

not in the Electronic Contract Management System, records for a sole source interim 

contract awarded on or about October 1, 2008, show that the justification for the interim 

contract was an “urgent and compelling” need because the existing contract was going 

to expire on September 30, 2008. It is not clear whether the contract that was going to 

expire was another interim contract or an improper extension of the prior contract. The 

interim contract was in effect from October 1, 2008, through March 30, 2009. Records 

show that the interim contract was extended through September 30, 2009, when 

another interim contract was awarded. The series of interim contracts with no effort to 

issue a solicitation for a long-term contract demonstrates poor acquisition planning. 

VA OIG Office of Healthcare Inspections 20 
Gillette, Powell, Pueblo, Anaheim, Laguna Hills, Escondido, Oceanside, Lancaster, and Sepulveda 

Appendix A 

VISN 19 Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: September 29, 2011
 

From: Director, VISN 19 (10N19)
 

Subject: CBOC Reviews: Gillette and Powell, WY; and Pueblo,
 

CO 

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

Director, Management Review Services (VHA 10A4A4) 

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

Outpatient Clinic (CBOC) Review of Gillette and Powell, WY and 

Pueblo, CO facilities. 

2.	 I concur with the recommendations and have ensured that action plans 

with target dates for completion were developed. 

3.	 If you have further questions regarding this CBOC review, please 

contact Aggie Worth, Quality Management Officer at 303-639-6984 or 

Susan Curtis, VISN 19 HSS at 303-639-6995. 

(original signed by:) 

Glen W. Grippen, FACHE 

Network Director 

VA OIG Office of Healthcare Inspections 21 
Gillette, Powell, Pueblo, Anaheim, Laguna Hills, Escondido, Oceanside, Lancaster, and Sepulveda 

Appendix B 

Sheridan VAMC Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: September 29, 2011
 

From: Director, Sheridan VAMC (666/00)
 

Subject: CBOC Review: Gillette and Powell, WY
 

To: Director, VA Rocky Mountain Network (10N19)
 

1.	 Attached please find the OIG Community Based Outpatient Clinic 

Review draft response from the Sheridan VA Medical Center. 

2.	 The Sheridan VA Medical Center and associated CBOCs has 

developed and is implementing the following action plans with the 

designated anticipated completion dates. 

3.	 Please contact Lisa McClintock at 307.675.3165 or myself at 

307.675.3675 with any questions or concerns regarding the following 

action plans. 

(original signed by:) 

Debra L. Hirschman 

Medical Center Director 

VA OIG Office of Healthcare Inspections 22 
Gillette, Powell, Pueblo, Anaheim, Laguna Hills, Escondido, Oceanside, Lancaster, and Sepulveda 

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 Sheridan VAMC establish a process 

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

at the Gillette and Powell CBOCs. 

Concur 

Target date for completion: 9/28/2011 

The Radiology Department within the Sheridan VAMC has modified the radiology 

ordering process for Short Term Fee care to include the approved justification. The 

justification is a component of the order that is completed prior to the scheduling of the 

procedure. 

Recommendation 2. We recommended that scopes of practice are facility-specific at 

the Powell CBOC. 

Concur 

Target date for completion: 10/31/2011 

Facility specific privileges for practice have been evaluated and discussed by the 

Medical Executive Board with modifications forthcoming. In addition, applications for 

privileges are being updated to clarify the range of privileges for the providers in the 

CBOCs. 

Recommendation 3. We recommended that adequate competency data be 

maintained in all providers’ profiles and that the Executive Committee of the Medical 

Staff meeting minutes reflect sufficient discussion of the competency data. 

Concur 

Target date for completion: 11/15/11 

The Sheridan VA Medical Center policy for collection of ongoing professional practice 

evaluation is being revised to define specific parameters for measurement and criteria 

for discussion/submission to Executive Committee of the Medical Staff. Each provider 

will have ongoing evaluation of data that equals 10 reviews per six months or 100% of 

Veterans seen if the volume is less than 10 during the review period. Meeting minutes 

of the Medical Executive Board have been strengthened to provide more detailed 

discussion of ongoing professional practice evaluation outcomes. 

VA OIG Office of Healthcare Inspections 23 
Gillette, Powell, Pueblo, Anaheim, Laguna Hills, Escondido, Oceanside, Lancaster, and Sepulveda 

Recommendation 4. We recommended that managers monitor and collect 

measurable data for hand hygiene at the Gillette and Powell CBOCs. 

Concur 

Target date for completion: 10/1/2011 

Each CBOC will have one responsible staff member for submission of hand hygiene 

data monthly. This data will be submitted to the Administrative Officer for the outpatient 

clinics to ensure that data is not lost in transition. The data will be copied and forwarded 

to the Infection Control nurse for trending. If the Infection Control nurse does not 

receive data, a written report will be sent to the responsible staff member in the CBOC 

with a copy to the CBOC Director. Data collection will include a combination of Veteran 

collected and staff observation data at a minimum of five each. 

Recommendation 5. We recommended that the PCMM Coordinator performs in 

accordance with VHA policy to reduce the number of veterans assigned to more than 

one PCP. 

Concur 

Target date for completion: 10/31/11 

In accordance with VHA policy the PCMM coordinator will access data related to dual 

assignments and the national listing of PCMM coordinators. The data will be utilized to 

identify and correct the patients with dual assignments and communicate with the 

appropriate PCMM coordinator in the other facility. This process will be ongoing with 

monthly validation of single assignments in PCMM and correction of dual assignments. 

Recommendation 6. We recommended that the facility investigate revamping the 

monthly billing validation process by providing the list of VA patients seen at the clinic to 

the Contractor that can be used as support for the monthly invoice. 

Concur 

Target date for completion: 10/31/2011 

Sheridan VA Medical Center CBOC/Telehealth service will implement a new billing 

validation process with the Contractor, Powell Valley Integrated Healthcare. The 

Sheridan VA Medical Center will provide a billing statement to the Contractor 

electronically with read only access to the supporting data. The Contractor will have 30 

days to submit changes for validation before it is submitted for payment. 

VA OIG Office of Healthcare Inspections 24 
Gillette, Powell, Pueblo, Anaheim, Laguna Hills, Escondido, Oceanside, Lancaster, and Sepulveda 

Appendix C 

VA Eastern Colorado HCS Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: September 28, 2011
 

From: Director, VA Eastern Colorado HCS (554/00)
 

Subject: CBOC Review: Pueblo, CO
 

To: Director, VISN 19 (10N19)
 

1.	 I acknowledge receipt of the Office of the Inspector General July 

CBOC report. 

2.	 As noted in the report, the Pueblo CBOC did not have any findings 

and as such we have not submitted an action plan. 

3.	 If there are any questions or concerns, please contact Rebecca 

Keough at (303) 249-9433. 

(original signed by:) 

Lynette A. Roff 

Director 

Eastern Colorado Health Care System 

VA OIG Office of Healthcare Inspections 25 
Gillette, Powell, Pueblo, Anaheim, Laguna Hills, Escondido, Oceanside, Lancaster, and Sepulveda 

Appendix D 

VISN 22 Director Comments 

Department of 

Veterans Affairs Memorandum 

Date:	 October 4, 2011 

From:	 Network Director, VA Desert Pacific Healthcare Network 

(10N22) 

Subject:	 CBOC Reviews: Anaheim and Laguna Hills, CA; 

Escondido and Oceanside, CA; and Lancaster and 

Sepulveda, CA 

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

Director, Management Review Services (VHA 10A4A4) 

1. This memo is to confirm Network Director concurrence for the 

open recommendations, VA Long Beach: 7-20; VA San Diego: 

21-27 and VA Greater Los Angeles: 28-38 of the Draft VISN 22 

July CBOC Report. 

2. If you have any questions regarding the information, please 

contact me at (562) 826-5963. 

(Original signed by:) 

Stan Johnson, MHA, FACHE 

Attachments 

VA OIG Office of Healthcare Inspections 26 
Gillette, Powell, Pueblo, Anaheim, Laguna Hills, Escondido, Oceanside, Lancaster, and Sepulveda 

Appendix E 

VA Long Beach HCS Director Comments 

Department of 

Veterans Affairs	 Memorandum 

Date: September 27, 2011
 

From: Director, VA Long Beach HCS (600/00)
 

Subject: CBOC Reviews: Anaheim and Laguna Hills, CA
 

To: Director, VA Desert Pacific Healthcare Network (10N22)
 

1.	 Please see attached response to the VA Office of Inspector General’s (OIG) 

Recommendation numbers 7 - 20 for the VA Long Beach Healthcare System 

CBOC Review conducted July 26-28, 2011. 

2. We concur with all recommendations. 

Isabel Duff, MS 

Attachment 

VA OIG Office of Healthcare Inspections 27 
Gillette, Powell, Pueblo, Anaheim, Laguna Hills, Escondido, Oceanside, Lancaster, and Sepulveda 

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 7. We recommended that at least one accessible VA or communitybased ED be identified where veterans at the Laguna Hills CBOC are directed to seek 

emergent care when necessary. 

Concur 

Target date for completion: 02/28/2012 

Response: VA Long Beach will work with Network Logistics Office to develop a 

contractual agreement with one community based Emergency Department where 

Veterans are transported for Mental Health emergent care when Veterans cannot be 

safely transported to VA Long Beach Emergency Department. This agreement will 

address the following: 

 sharing medical information 

 financial arrangements for payment of authorized emergency care 

The Laguna Hills staff will document in the medical record when 911 is called and 

include the name of the facility the Veteran is transported to and inform the Transfer 

Coordinator/designee via a transfer consult, of the patient’s transfer to a communitybased facility. The Transfer Coordinator will notify the Chiefs of the Mental Health Care 

Group of any transfers from the Laguna Hills CBOC. Incidents will be provided to the 

Clinical Practice Executive Council (CPEC) on a quarterly basis. 

Recommendation 8. We recommended that the VA Long Beach HCS develop a local 

policy for Short-Term Fee Basis consults. 

Concur 

Target date for completion: 12/15/11 

Response: A Standard Operating Procedure was developed and implemented during 

the OIG CBOC site visit outlining Short-Term Fee Basis consults. A Healthcare System 

Policy (HSP) draft is being developed with review targeted for 10/15/11 and full 

implementation/approval by 11/15/11. 

Recommendation 9. We recommended that the copies of Short-Term Fee Basis 

reports for patients at the Laguna Hills CBOC are filed or scanned into the medical 

record. 

Concur 

VA OIG Office of Healthcare Inspections 28 
Gillette, Powell, Pueblo, Anaheim, Laguna Hills, Escondido, Oceanside, Lancaster, and Sepulveda 

Target date for completion: 12/15/2011 

Response: The Fee Basis section of Financial Management will modify via the 

Contracting Office, the Valor Healthcare, Inc. contract to include language to direct all 

imaging results submitted to the Veterans Affairs Medical Center, Long Beach CA, by 

courier for entry into CPRS. An auditing process will be implemented to ensure 

compliance by Valor Healthcare, Inc. Fee Basis will perform a monthly review of all 

closed fee consults to ensure that imaging results have been provided and uploaded to 

CPRS. The results of this review will be reported on a quarterly basis to the 

Management and Operations Executive Council. 

Recommendation 10. We recommended that the Anaheim and Laguna Hills CBOC 

managers establish a process to ensure patients with normal mammograms are 

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

is documented in the medical record. 

Concur 

Target date for completion: 09/26/2011 

Response: The mammography technologists have been retrained on the requirement 

to document via a progress note in Vista/CPRS that a letter has been sent to the 

Veteran providing the results of their normal mammogram exam. The Chief 

Technologist or his/her designee will monitor this process on a weekly basis and will 

report to the Chief of the Radiology/Nuclear Medicine Imaging Service. The Chief 

Technologist will perform a monthly audit to ensure that the progress notes are being 

completed. Results of the monthly audits will be provided to the Clinical Practice 

Executive Council (CPEC) on a quarterly basis. 

Recommendation 11. We recommended that patients with abnormal mammography 

results at the Laguna Hills CBOC are notified by their provider within 14 calendar days 

and notification is documented in the medical record. 

Concur 

Target date for completion: Completed 

Response: Laguna Hills CBOC Providers have been re-educated and are immediately 

notifying all Veterans of abnormal mammography results. The Laguna Hills CBOC 

manager will submit a monthly report of all patients having mammograms and evidence 

that patients are informed immediately of abnormal results and follow up. The Chief, 

PC&SC HCG will monitor this report monthly and submit quarterly updates to the 

Medical Executive Council (MEC) or more often as necessary until 100% compliance is 

maintained, and then intermittently review. 

Recommendation 12. We recommended that FPPEs be initiated for all physicians 

who have been newly hired at the Laguna Hills CBOC. 

VA OIG Office of Healthcare Inspections 29 
Gillette, Powell, Pueblo, Anaheim, Laguna Hills, Escondido, Oceanside, Lancaster, and Sepulveda 

Concur 

Target date for completion: 11/01/2011 

Response: FPPEs will be completed for every newly hired provider at the Laguna Hills 

CBOC within 90 days. These FPPEs will be submitted to the respective HCG Chief 

(Mental Health HCG and Primary Care & Specialty Clinics HCG). The HCG Chiefs will 

review the FPPEs and place this information in the Provider’s employee folder that will 

be maintained by each VA Long Beach Health Care Group (HCG). The Chiefs, PC&SC 

and Mental Health HCG will review this report and submit quarterly updates to the 

Medical Executive Council (MEC). 

Recommendation 13. We recommended that adequate competency data be 

maintained in all providers’ profiles at the Laguna Hills CBOC. 

Concur 

Target date for completion: 11/01/2011 

Response: All Providers at Laguna Hills will have Ongoing Professional Practice 

Evaluations (OPPE) completed quarterly and this information will be forwarded to the 

respective HCG Chief. The HCG Chiefs will review the OPPEs and place this 

information in the Provider’s employee folder that will be maintained by each VA Long 

Beach Health Care Group (HCG). The Chiefs, PC&SC and Mental Health HCG will 

review this report and submit quarterly updates to the Clinical Practice Executive 

Council (CPEC). 

Recommendation 14. We recommended that the competency policy at the Anaheim 

CBOC define who is responsible for competency validation and the process for the 

selection of qualified personnel to assess and validate competencies. 

Concur 

Target date for completion: 12/15/2011 

Response: The Human Resources Competency Committee will ensure the 

competency guidelines are updated to address who is responsible for competency 

validation and the process for the selection of qualified personnel to assess and validate 

competencies. The Management and Operations Executive Council will be responsible 

to monitor that this policy has been completed by the target date. 

Recommendation 15. We recommended that a competency policy be developed for 

staff at the Laguna Hills CBOC that defines required core competencies, includes who 

is responsible for validation, identifies the process for selecting qualified personnel to 

validate competencies, and denotes the actions taken when staff cannot demonstrate 

competency. 

Concur 

VA OIG Office of Healthcare Inspections 30 
Gillette, Powell, Pueblo, Anaheim, Laguna Hills, Escondido, Oceanside, Lancaster, and Sepulveda 

Target date for completion: 1/15/2012 

Response: The Human Resources Competency Committee will ensure the 

competency guidelines for VA Long Beach Healthcare System are updated. Once the 

policy is completed, the Laguna Hills CBOC will utilize this for a template for their policy. 

The Management and Operations Executive Council (MOEC) will be responsible to 

monitor that this policy has been completed by the target date. 

Recommendation 16. We recommended that staff competencies at the Anaheim 

CBOC are assessed annually in accordance with local policy. 

Concur 

Target date for completion: 1/15/2012 

Response: Primary Care and Specialty Clinics HCG will ensure that staff completes 

their core competencies annually. PC&S HCG will submit reports to the Human 

Resources Competency Committee to assure compliance on a quarterly basis. 

Recommendation 17. We recommended that the PCMM Coordinator performs in 

accordance with VHA policy to perform panel assignment after completion of the 

patient’s first appointment. 

Concur 

Target date for completion: 10/03/2011 

Response: A new Fileman data report has been developed and implemented that will 

identify patients that have been initially seen by a Primary Care Provider (PCP) and not 

assigned to a PCP. This report will be run daily to capture patients who have not been 

assigned to a permanent Primary Care Provider. The PCMM Coordinator/designee will 

assign these patients a PCP, after the initial primary care visit. The Chief of Data, 

Collection and Analysis will monitor compliance monthly and report quarterly to the 

Management and Operations Executive Council (MOEC). 

Recommendation 18. We recommended that the PCMM Coordinator performs in 

accordance with VHA policy to reduce the number of veterans assigned to more than 

one PCP. 

Concur 

Target date for completion: 11/15/2011 

Response: The PCMM Coordinator has been retrained to utilize the VSSC dual 

enrolled patient list and to conduct dual assignment reviews on a weekly basis. The 

PCMM Coordinator will collaborate with other sites to remove patients on the dual 

enrolled list and ensure that those that do not belong to VA Long Beach are also 

removed. The Chief, Data Collection and Analysis will conduct monthly audits using the 

VA OIG Office of Healthcare Inspections 31 
Gillette, Powell, Pueblo, Anaheim, Laguna Hills, Escondido, Oceanside, Lancaster, and Sepulveda 

VSSC dual enrolled patient list and report results quarterly to the Management & 

Operations Executive Council. 

Recommendation 19. We recommended that the Contracting Officer ensures the 

contract clearly states the requirements for payment. 

Concur 

Target date for completion: 10/15/2011 

Response: The Contracting Officer will modify the contract to include updated Invoice 

and Payment language in accordance with FAR 52.212-4(g) and (i). This modification 

will include how monthly payments will be made using capitated rates for enrolled 

Veterans and provide proper invoice submission instructions. The Contracting Officer 

will provide a copy of the modification to the COTR when complete. The COTR will 

report contract compliance to Management & Operations Executive Council on a 

quarterly basis. 

Recommendation 20. We recommended that the Contracting Officer add provisions to 

the contract that requires reimbursement to the VA when a prepaid annual capitated 

rate for disenrolled patients and when the remaining contract period is less than a year. 

Concur 

Target date for completion: 10/01/2011 

Response: The Contracting Officer will modify the contract to include the 

reimbursement requirements and repayment plan when the contract period is less than 

a year and the VA has paid an annual capitated rate for a disenrolled patient. The 

COTR will monitor potential disenrolled Veteran contract repayment options and report 

to the Contracting Officer as directed in the modification. The COTR will report contract 

compliance to Management & Operations Executive Council on a quarterly basis. 

VA OIG Office of Healthcare Inspections 32 
Gillette, Powell, Pueblo, Anaheim, Laguna Hills, Escondido, Oceanside, Lancaster, and Sepulveda 

Appendix F 

VA San Diego HCS Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: September 28, 2011 

From: Acting Director, VA San Diego HCS (664/00) 

Subject: CBOC Reviews: Escondido and Oceanside, CA 

To: Director, VA Desert Pacific Healthcare Network (10N22) 

1. Enclosed are the responses to the recommendations in the 

draft Office of the Inspector General’s report of our 

Community Based Outpatient Clinic (CBOC) review in 

Escondido and Oceanside. 

2. If you have questions or wish to discuss the report, please 

contact me at (858) 642-3201. 

(original signed by:) 

Robert M. Smith, MD 

Acting Director, VA San Diego Healthcare System 

VA OIG Office of Healthcare Inspections 33 
Gillette, Powell, Pueblo, Anaheim, Laguna Hills, Escondido, Oceanside, Lancaster, and Sepulveda 

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 21. We recommended that the facility develop a local policy for 

Short-Term Fee Basis consults. 

Concur 

Target date for completion: October 2011 

VA Central Office will be implementing a standardized process for handling Fee Basis 

consults in FY 2012. Implementation of this process is scheduled for VISN 22 in the 

second quarter of March 2012. The VA San Diego HCS will develop a local policy that 

reflects national standards as part of this implementation process. 

While National and VISN direction are pending, the VA San Diego HCS will develop and 

publish an interim local policy. 

Recommendation 22. We recommended that the copies of Short-Term Fee Basis 

reports for patients at the Escondido CBOC are filed or scanned into the medical record. 

Concur 

Target date for completion: January 2012 

It is the policy of the Escondido CBOC that once it receives an imaging report as a 

result of Short-Term Fee Basis consult that the report is given to the patient’s provider 

for review immediately. The provider notes their review in CPRS and then calls the 

patient to communicate the findings and the plan of care. The report is then forwarded 

to the Health Information Management Section of the Health Administration Service 

(HAS) for scanning into CPRS. This process is usually completed within 24 hours of the 

Provider receiving the report, and never beyond the seven days that is required by 

policy. The scanning of the report into CPRS occurs within 24 hours if received by 12 

noon; those received after 12 noon are scanned the following business day. The 

instance where the Short-Term Fee Basis imaging report was not scanned into the 

patient’s record has since been corrected. The aforementioned policy will be enforced 

and monitored by HAS. An internal audit will be performed to assure the process is 

being properly followed. 

Recommendation 23. We recommended that the ordering practitioners, or surrogate 

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

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

CBOC. 

VA OIG Office of Healthcare Inspections 34 
Gillette, Powell, Pueblo, Anaheim, Laguna Hills, Escondido, Oceanside, Lancaster, and Sepulveda 

Concur 

Target date for completion: January 2012 

As noted in response to Recommendation 22, it is the policy of the Escondido CBOC 

that once it receives an imaging report as a result of Short-Term Fee Basis consult that 

the report is given to the patient’s provider for review immediately. The provider notes 

their review in CPRS and then calls the patient to communicate the findings and the 

plan of care. This process is usually complete within 24 hours of the provider receiving 

the report. The providers who failed to document their communications of the ShortTerm Fee Basis results to the patient within 14 days from the date made available to the 

ordering practitioner will be reminded of the policy by the CBOC COTR and asked to 

document their communications of results in CPRS. An audit will be performed to 

assure the process is being properly followed. 

Recommendation 24. We recommended that the auditory privacy be maintained 

during check-in process at the Escondido CBOC. 

Concur 

Target date for completion: January 2012 

The check-in process at the Escondido CBOC will be revised so that the zone of 

auditory privacy is monitored and maintained. Additionally, staff will begin to swipe the 

Veterans VA ID card as the method for identify patients as opposed to asking them to 

provide their name and the last four digits of their social security number verbally. The 

VA San Diego HCS will audit the process for auditory privacy compliance after the 

implementation of process changes. 

Recommendation 25. We recommended that the MH front-desk staff at the Oceanside 

CBOC receive portable silent alarm call buttons. 

Concur 

Target date for completion: Completed as of September 1, 2011 

MH front-desk staff at the Oceanside CBOC received portable silent alarm call buttons 

shortly after the OIG review. 

Recommendation 26. We recommended that signage be installed to identify the 

location of fire extinguishers at the Oceanside CBOC. 

Concur 

Target date for completion: October 2011 

VA OIG Office of Healthcare Inspections 35 
Gillette, Powell, Pueblo, Anaheim, Laguna Hills, Escondido, Oceanside, Lancaster, and Sepulveda 

Fire extinguisher signage was ordered and recently arrived at the VA San Diego HCS. 

Those will be installed prior to the end of October 2011. 

Recommendation 27. We recommended that the VISN Director and VHA Sharing 

Office take appropriate steps to ensure to award a competitive long-term contract and 

that requests for interim contracts comply with the provisions of VA Directive 1663. 

Concur 

Target date for completion: October 2011 

The VA San Diego HCS and the VISN 22 Office have worked diligently and 

cooperatively with the Network Contacting Activity (NCA), formerly the Network 

Logistics Office, to award a competitive long-term contract in the Escondido area. 

However, for reasons beyond the scope of responsibility and control of the HCS and the 

VISN, the NCA has been unable to award a long-term CBOC contract in the Escondido 

area for the past five years. The long-term Escondido CBOC contract originally 

extended from February 2001 to August 2006 for a total of five years; it was a four year 

contract with a one-year option. The first interim contract or extension lasted from 

August 2006 to October 2006. Then there were two one-year extensions from 

November 2006 through November 2008. Since November 2008 there have been 

several extensions ranging from three to six months. Currently, the Escondido CBOC is 

operating under a three month extension that will expire at the end of October 2011. 

The VA San Diego HCS and the VISN 22 Office will continue to work diligently and 

cooperatively with the NCA to award a long-term contract for the Escondido CBOC. 

Network Contracting Activity (NCA) Response: The Escondido CBOC solicitation is in 

evaluation with an estimated award expected by October 2011. The interim contract for 

Escondido is current and was approved by the Medical Sharing Office (Washington 

DC). The NCA is complying with the provisions of VA Directive 1663. 

VA OIG Office of Healthcare Inspections 36 
Gillette, Powell, Pueblo, Anaheim, Laguna Hills, Escondido, Oceanside, Lancaster, and Sepulveda 

Appendix G 

VA Greater Los Angeles HCS Director Comments 

Department of 

Veterans Affairs	 Memorandum 

Date: October 12, 2011 

From: Director, VA Greater Los Angeles Healthcare System (691/00) 

Subject: CBOC Reviews: Lancaster and Sepulveda, CA 

To: Director, VA Desert Pacific Healthcare Network (10N22) 

1.	 Please find the following comments in response to the 

recommendations 28-38 in the OIG’s report. Corrective 

action plans have been established with planned 

completion dates, as detailed in the attached report. 

2.	 Should you have further questions or comments, please 

contact Ms. Joan Lopes, Chief, Quality Management, at 

(310) 268-3585. 

Sincerely, 

(original signed by:) 

Donna M. Beiter, R.N., M.S.N 

Attachments 

VA OIG Office of Healthcare Inspections 37 
Gillette, Powell, Pueblo, Anaheim, Laguna Hills, Escondido, Oceanside, Lancaster, and Sepulveda 

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 28. We recommended that the Professional Standards Board 

grant privileges consistent with the services provided at the Lancaster and 

Sepulveda CBOCs. 

Concur 

Target date for completion: November 14, 2011 

A total of 34 providers were identified in Primary/Ambulatory Care setting: 

1. Bakersfield 5 

2. LAACC 7 

3. SLO 2 

4. Santa Barbara 3 

5. Santa Maria 4 

6. Sepulveda 12 

7. Lancaster 1 

A memo addressing each providers’ specific privileges will be added to their clinical 

privilege file. In addition, this action will be discussed and documented by the 

Professional Standards Board. 

Recommendation 29. We recommended that access is improved for disabled 

veterans at the Lancaster CBOC. 

Concur 

Target date for completion: January 2012 

GLA is currently working with Network Contracting Officers to include improvement 

of access to the Lancaster CBOC for disabled veterans which will meet the 

standards of the American Disability Act. Due to current contract status, this cannot 

be fully addressed until a new contract is awarded. The solicitation process has 

been initiated by Network Contracting. 

Recommendation 30. We recommended that fire drills be conducted annually at the 

Sepulveda CBOC. 

Concur 

Target date for completion: December 31, 2011 

VA OIG Office of Healthcare Inspections 38 
Gillette, Powell, Pueblo, Anaheim, Laguna Hills, Escondido, Oceanside, Lancaster, and Sepulveda 

Fire drills are conducted annually in all business occupancies. The deficiency 

resulting in counting a false alarm as a fire drill which moved the actual drill date into 

the previous year was due to the fact that our fire drill are done on a FY versus a CY. 

In the future false alarms will not be counted as the actual date, but the actual date 

they are scheduled. New schedule has been established to assure annual testing. 

Recommendation 31. We recommended that fire and life safety inspections be 

conducted annually at the Sepulveda CBOC. 

Concur 

Target date of completion: Start date 09/30/2011 

The fire & life safety inspections for Sepulveda CBOC have been scheduled to be 

conducted annual and all required elements. 

Recommendation 32. We recommended that two patient identifiers are used by 

staff when providing care, treatment, and services at the Lancaster CBOC. 

Concur 

Target date for completion: Start date 9/27/2011 

In September 2011, monthly agenda item for staff meetings will include spot 

checking of staff for use of two patient identifiers to monthly quality management 

report. Administrator developed tool for observation of all staff that will be reported to 

the COTR. 

Recommendation 33. We recommended that the PCMM Coordinator performs in 

accordance with VHA policy to reduce the number of veterans assigned to more 

than one PCP. 

Concur 

Target date for completion: On-going 

The dual report was removed for “re-construction” from the VSSC, which resulted in a 

lapse in current dual data. Prior to the OIG Inspection, we relied on older dual reports 

to reduce the number of dually assigned patients. During the inspection, we learned 

that data was embedded in the PC Almanac. We have been using this data to remove 

veterans who are assigned to more than one PCP. As of today (10/7/11) Lancaster is 

at 222 (5.6%) duals and Sepulveda is at 893 (5.9%). In FY12, we will strive for less 

than 2% for each site. We will continue to post unassigned and dual data on our local 

secured SharePoint site for site managers to take appropriate action. 

VA OIG Office of Healthcare Inspections 39 
Gillette, Powell, Pueblo, Anaheim, Laguna Hills, Escondido, Oceanside, Lancaster, and Sepulveda 

Recommendation 34. We recommended that the Facility Director and Contracting 

Officer ensure that there are performance incentive/penalty provisions in the 

contract, particularly those related to VHA quality of medical care standards. 

Concur 

Target date for completion: Upon contract award 

Whereas the new solicitation contains a QASP, this QASP does not reflect recently 

approved performance incentives/penalties. Upon award of the new contract, it will be 

modified to include the performance incentives/penalties. Because this is a VA wide 

implementation, all contractors concerned in this solicitation are aware of this 

modification based on discussion with the contracting officer regarding this CBOC or 

other CBOC that they may operate. 

Recommendation 35. We recommended that the VISN Director and VHA Sharing 

Office take appropriate steps to ensure that medical contracting is performed in 

accordance with applicable laws, regulations, and policies, and that interim contracts 

are approved in advance by VHA’s Medical Sharing Office as required by VA 

Directive 1663. 

Concur 

Target date for completion: Upon contract decision and before approval. 

The contract is expected to be awarded on or about October 31, 2011. The solicitation 

has not been sent to Medical Sharing. Prior to award, a copy of the contract and 

proposal of the intended awardee will be forwarded to the Medical Sharing Office for 

review. This process has already been incorporated into a VA standardized contract 

quality assurance checklist. We will ensure that all future contracts are administered in 

accordance with applicable laws, regulations and policies. Award cannot be made 

without completion of the checklist which is reviewed by a 3rd party outside of the 

network contracting office. 

Recommendation 36. We recommended that the VISN Director, Contracting 

Office, and Facility Director take the steps necessary to award a long-term contract 

to obtain required services for the Lancaster CBOC. 

Concur 

Target date for completion: October 31, 2011 

Yes, this contract is for a base plus 4 option years, putting in place a long term solution 

for this CBOC. As for future CBOC acquisition planning, authority and responsibility for 

all CBOC acquisitions has been centralized at the Network Contracting Activity under 

the Medical Sharing Team. Prior to this centralization of authority, and due to a 

shortage of personnel and a re-organization at the NCA, CBOC responsibilities were 

VA OIG Office of Healthcare Inspections 40 
Gillette, Powell, Pueblo, Anaheim, Laguna Hills, Escondido, Oceanside, Lancaster, and Sepulveda 

delegated to various contract specialists throughout the organization. In the new 

structure, one team (perhaps no more than 3 people) will have total contract 

responsibility for all VISN 22 capitated CBOCs. 

Recommendation 37. We recommended that the facility has a complete copy of all 

applicable contracts and ensures that all invoices are appropriately validated so VA 

resources are accurately expended. 

Contracts are available and invoice validation is on-going. 

Concur 

Target date for completion: On-going and report of status November 30, 2011. 

All documentation relative to CBOC awards are routinely forwarded from the contracting 

officer to the COTR. However to ensure that the COTR has copies of all documents, 

monthly meetings between the CO, COTR, and Program Managers have been 

initiated. Additionally, standardized post award procedures have been implemented 

which require a post award conference and distribution of pertinent documents to the 

contractor and COTR within a few days after contract award. In addition, we now use 

the VISTA program to check current number of active qualifying patients. The contractor 

provides a list of new patients and they are checked for means tests and eligibility. The 

information is accurate and fast. The Program also provides a list of patients to be 

removed from the invoice as well. The information is reviewed and sent on to the 

contractor. 

Recommendation 38. We recommended that the Facility Director and Contracting 

Officer confer with Regional Counsel to determine the amount and collectability of the 

overpayments. 

Concur 

Target date for completion: November 30, 2011 

The Facility Director and Contracting Officer are in communication for a meeting with 

Regional Counsel to determine amounts and collectability. 

VA OIG Office of Healthcare Inspections 41 
Gillette, Powell, Pueblo, Anaheim, Laguna Hills, Escondido, Oceanside, Lancaster, and Sepulveda 

Appendix H 

OIG Contact and Staff Acknowledgments 

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

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

Contributors	 Nancy Albaladejo, RN 

Gail Bozzelli, RN 

Shirley Carlile, BA 

Marisa Casado, RN, MSA 

Lin Clegg, PhD 

Marnette Dhooghe, MS 

Laura Dulcie, BSEE 

Nathan Fong, CPA 

Stephanie Hensel, RN, JD 

Stephanie Hills, RN, MSN 

Zhana Johnson, CPA 

Sandra Khan, RN 

Anthony M. Leigh, CPA 

Sarah Lutter, RN, JD 

Sami O’Neill, MA 

Jennifer Reed, RN 

Noel Rees, MPA 

Thomas J. Seluzicki, CPA 

Marilyn Stones, BS 

Ann Ver Linden, RN, MBA 

Cheryl Walker, ARNP, MBA 

VA OIG Office of Healthcare Inspections 42 
Gillette, Powell, Pueblo, Anaheim, Laguna Hills, Escondido, Oceanside, Lancaster, and Sepulveda 

Appendix I 

Report Distribution 

VA Distribution 

Office of the Secretary
 

Veterans Health Administration
 

Assistant Secretaries
 

General Counsel
 

Director, VISN 19 (10N19)
 

Director, Sheridan VAMC (666/00)
 

Director, VA Eastern Colorado HCS (554/00)
 

Director, VISN 22 (10N22)
 

Director, VA Long Beach HCS (600/00)
 

Director, VA San Diego HCS (664/00)
 

Director, VA Greater Los Angeles HCS (691/00)
 

Non-VA Distribution 

House Committee on Veterans’ Affairs 

House Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

House Committee on Oversight and Government Reform 

Senate Committee on Veterans’ Affairs 

Senate Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

Senate Committee on Homeland Security and Governmental Affairs 

National Veterans Service Organizations 

Government Accountability Office 

Office of Management and Budget 

U.S. Senate: John Barrasso, Michael F. Bennet, Barbara Boxer, Michael B. Enzi, 

Dianne Feinstein, Mark Udall 

U.S. House of Representatives: Howard L. Berman, Brian P. Bilbray, John Campbell, 

Duncan D. Hunter, Darrell E. Issa, Doug Lamborn, Cynthia M. Lummis, Kevin 

McCarthy, Howard P. McKeon, Gary G. Miller, Edward R. Royce, Loretta Sanchez, 

Brad Sherman, Scott Tipton 

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

VA OIG Office of Healthcare Inspections 43