Department of Veterans Affairs 

Office of Inspector General 

Office of Healthcare Inspections
 

Report No. 11-01406-228 

Community Based Outpatient
 

Clinic Reviews
 

Branson, MO and Harrison, AR
 

Conroe and Lufkin, TX
 

Hammond and Houma, LA
 

July 18, 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) 
Branson, Harrison, Conroe, Lufkin, Hammond, and Houma 

Glossary
 

C&P 

CBOC 

COTR 

CPRS 

CT 

DX & TX Plan 

ED 

EKG 

EOC 

FPPE 

FTE 

FY 

HCS 

IT 

LCSW 

MedMgt 

MH 

MRI 

MST 

NP 

OIG 

OPPE 

PCMM 

PCP 

PET 

PII 

PSB 

PSTP 

PTSD 

Qtr 

TX 

VAMC 

VHA 

VISN 

VistA 

credentialing and privileging 

community based outpatient clinic 

Contracting Officer’s Technical Representative 

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 

Licensed Clinical Social Worker 

medication management 

mental health 

Magnetic Resonance Imaging 

military sexual trauma 

nurse practitioner 

Office of Inspector General 

Ongoing Professional Practice Evaluation 

Primary Care Management Module 

primary care provider 

Positron Emission Tomography 

personally identifiable information 

Professional Standards Board 

psychotherapy 

Post-Traumatic Stress Disorder 

quarter 

treatment 

VA Medical Center 

Veterans Health Administration 

Veterans Integrated Service Network 

Veterans Health Information Systems and 

Technology Architecture 

VA OIG Office of Healthcare Inspections 
Branson, Harrison, Conroe, Lufkin, Hammond, and Houma 

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............................................................................................. 6
 

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

C&P ........................................................................................................................ 10
 

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

Environment and Emergency Management............................................................ 12
 

PCMM..................................................................................................................... 15
 

CBOC Contract....................................................................................................... 15
 

Appendixes 

A. VISN 16 Director Comments ............................................................................. 18
 

B. Veterans HCS of the Ozarks Director Comments.............................................. 19
 

C. Michael E. DeBakey VAMC Director Comments............................................... 22
 

D. Southeast Louisiana Veterans HCS Director Comments .................................. 26
 

E. OIG Contact and Staff Acknowledgments ......................................................... 31
 

F. Report Distribution............................................................................................. 32
 

VA OIG Office of Healthcare Inspections 
Branson, Harrison, Conroe, Lufkin, Hammond, and Houma 

Executive Summary
 

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

April 11, 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 

16 Veterans HCS of the Ozarks 

Branson, MO 

Harrison, AR 

Michael E. DeBakey VAMC Conroe, TX 

Lufkin, TX 

Southeast Louisiana Veterans HCS Hammond, LA 

Houma, LA 

Table 1. Sites Inspected 

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

respective CBOC managers, should take appropriate actions to: 

Veterans HCS of the Ozarks 

	 Ensure that the PCMM Coordinator’s duties are performed in accordance with VHA 

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

	 Ensure all ancillary charges are defined, specifically all laboratory test 

reimbursement rates, by the Contracting Officer. 

	 Ensure the provisions of the contract are enforced specifically adhering to the 

invoice format in the contract. 

Michael E. DeBakey VAMC 

	 Ensure providers document a justification for the use of Short-Term Fee Basis care 

in the medical record at the Conroe CBOC. 

	 Ensure veterans receive written notification when a Short-Term Fee Basis consult is 

approved and that the notification is documented in the medical record at the Conroe 

and Lufkin CBOCs. 

	 Require that Short-Term Fee Basis consults are approved by appropriate leadership 

or a designee in accordance with VHA policy at the Lufkin CBOC. 

	 Ensure copies of Short-Term Fee Basis reports are filed or scanned in the electronic 

medical record at the Lufkin CBOC. 

	 Ensure that managers establish a process to document patient notification results in 

the medical record at the Lufkin CBOC. 

VA OIG Office of Healthcare Inspections i 
Branson, Harrison, Conroe, Lufkin, Hammond, and Houma 

	 Establish a process to ensure CPRS mammogram radiology orders are entered for 

all fee basis and contract mammograms and that all breast imaging and 

mammography results are linked to the appropriate radiology mammogram or breast 

study order at the Conroe and Lufkin CBOCs. 

	 Grant privileges consistent with the services provided at the Conroe and Lufkin 

CBOCs. 

	 Ensure all volunteers with access to PII receive and maintain annual privacy 

awareness training in accordance with local policy at the Conroe CBOC. 

Southeast Louisiana Veterans HCS 

	 Ensure the facility develops a local policy for Short-Term Fee Basis consults for the 

Hammond and Houma CBOCs. 

	 Ensure providers document a justification for the use of Short-Term Fee Basis care 

in the medical record at the Hammond and Houma CBOCs. 

	 Ensure veterans receive written notification when a Short-Term Fee Basis consult is 

approved and that the notification is documented in the medical record at the 

Hammond and Houma CBOCs. 

	 Require the ordering practitioners, or surrogate practitioners, to document in the 

medical record that they reviewed the report and communicated the results to the 

patient within 14 days from the date the results of the Short Term Fee Basis consult 

is made available to the ordering practitioner at the Hammond and Houma CBOCs. 

	 Grant privileges consistent with the services provided at the Hammond and Houma 

CBOCs. 

	 Ensure that the service chief’s documentation in VetPro reflects documents 

reviewed and the rationale for privileging or re-privileging at the Hammond and 

Houma CBOCs. 

	 Evaluate the use of the IT closet and implement appropriate measures according to 

VA policy at the Houma CBOC. 

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

	 Install signage to identify the location of fire extinguishers at the Houma CBOC. 

	 Maintain the security of patients’ PII at the Hammond and Houma CBOCs. 

	 Ensure that all contract terms are clearly defined for requirements of payments, 

specifically the term vesting encounter, by the Contracting Officer. 

VA OIG Office of Healthcare Inspections ii 
Branson, Harrison, Conroe, Lufkin, Hammond, and Houma 

	 Determine the total amount of overpayments to the contractor during the contract 

period as a result of ineligible patients and, with the assistance of the Regional 

Counsel, assess the collectability of the overpayment. 

	 Ensure the provisions of the contract are enforced, specifically the invoice format in 

the contract. 

Comments 

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

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

pages 18–30 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 iii 
Branson, Harrison, Conroe, Lufkin, Hammond, and Houma 

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 
Branson, Harrison, Conroe, Lufkin, Hammond, and Houma 

 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 
Branson, Harrison, Conroe, Lufkin, Hammond, and Houma 

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

CBOCs and specific characteristics. 

Branson Harrison Conroe Lufkin Hammond Houma 

VISN 16 16 16 16 16 16 

Parent Facility Veterans HCS 

of the Ozarks 

Veterans HCS 

of the Ozarks 

Michael E. DeBakey 

VAMC 

Michael E. DeBakey 

VAMC 

Southeast 

Louisiana 

Veterans HCS 

Southeast 

Louisiana Veterans 

HCS 

Type of CBOC VA Contract VA VA VA Contract 

Number of Uniques,5 FY 2010 5,340 1,849 7,432 6,544 3,207 3,977 

Number of Visits, FY 2010 25,549 6,654 39,173 49,423 14,783 18,223 

CBOC Size6 Large Mid-size Large Large Mid-size Mid-size 

Locality Rural Rural Rural Rural Rural Urban 

FTE PCP 4.0 1.2 5.9 4.5 2.9 3.0 

FTE MH 4 1 4 10 2 3 

Types of Providers PCP 

NP 

Psychiatrists 

Psychologist 

LCSW 

Internal 

Medicine 

Provider 

PCP 

NP 

Internal Medicine 

Provider 

PCP 

PA 

Psychiatrists 

Psychologist 

LCSW 

Clinical Pharmacist 

Internal Medicine 

Provider 

PCP 

NP 

PA 

Psychiatrists 

Psychologist 

LCSW 

Internal Medicine 

Provider 

NP 

Psychiatrists 

Psychologist 

LCSW 

Audiologist 

PCP 

NP 

PA 

Psychiatrists 

Psychologist 

LCSW 

Specialty Care Services Onsite No Yes Yes Yes No Yes 

Procedures Performed Onsite None None None None None None 

Tele-Health Services Tele-Retinal None None Tele-Retinal Tele-Medicine 

Tele-Retinal 

Tele-Retinal 

Tele-Radiology 

Ancillary Services Provided 

Onsite 

Laboratory 

Radiology 

EKG 

Tele-Retinal 

Imaging 

Laboratory 

Radiology 

EKG 

Laboratory 

EKG 

Pulmonary tests 

Laboratory 

Pharmacy 

Radiology 

EKG 

Laboratory 

Pharmacy 

EKG 

Laboratory 

Radiology 

EKG 

Satellite Clinic None None None None None None 

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 
Branson, Harrison, Conroe, Lufkin, Hammond, and Houma 

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 CBOC to respond to patients’ MH needs. 

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

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

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

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

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

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

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

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

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

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

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

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

well as tele-mental health. 

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

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

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

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

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

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

care management; psychosocial rehabilitation services including family education, skills 

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

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

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

CBOC reviewed. 

7 VHA Handbook 1160.01. 

VA OIG Office of Healthcare Inspections 4 
Branson, Harrison, Conroe, Lufkin, Hammond, and Houma 

Mental Health CBOC Characteristics 

Branson Harrison Conroe Lufkin Hammond Houma 

Provides MH 

Services 

Yes Yes Yes Yes Yes Yes 

Number of MH 

Uniques, FY 2010 

606 204 1,588 1,625 1,000 1,334 

Number of MH 

Visits 

4,211 614 5,075 12,676 4,644 9,333 

General MH DX & TX Plan DX & TX Plan DX & TX Plan DX & TX Plan DX & TX Plan DX & TX Plan 

Services MedMgt 

PSTP 

PTSD 

MST 

MedMgt 

PSTP 

PTSD 

MST 

MedMgt 

PSTP 

PTSD 

MST 

MedMgt 

PSTP 

PTSD 

MST 

MedMgt 

PSTP 

PTSD 

MST 

MedMgt 

PTSD 

MST 

Specialty MH Consult & TX Consult & TX Consult & TX Consult & TX Consult & TX None 

Services PSTP PSTP PSTP Homeless Program 

Specialty Substance MHCIM PRRC 

Abuse Treatment Social Skills 

Services Peer Support 

PTSD Teams 

Tele-Mental Health Yes Yes Yes No Yes Yes 

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

Fee basis 

Another VA Facility 

Fee basis 

Table 3. MH Characteristics for CBOCs 

VA OIG Office of Healthcare Inspections 5 
Branson, Harrison, Conroe, Lufkin, Hammond, and Houma 

Emergency Plan 

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

care at CBOCs.8 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 

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 

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

recommendations. 

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. 

8 VHA Handbook 1160.01. 

VA OIG Office of Healthcare Inspections 6 
Branson, Harrison, Conroe, Lufkin, Hammond, and Houma 

Noncompliant Areas Reviewed 

Hammond 

Houma 

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

and services purchased by authority that describes the request, 

approval, and authorization process for such services.9 

Conroe 

Hammond 

Houma 

The provider documented a justification for using Fee Basis status 

in lieu of providing staff treatment as required by VHA policy.10 

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

the date the consult was initiated. 

Lufkin 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.11 

Conroe Patients were notified of consult approvals in writing, and 

Lufkin notifications are documented in the patients' medical record as 

Hammond required by VHA policy.12 

Houma 

Lufkin A copy of the imaging report is in CPRS according to VHA policy.13 

There is evidence the ordering provider or surrogate practitioner 

reviewed the report. 

Hammond 

Houma 

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.14 

Table 5. Short-Term Fee Basis 

VISN 16, Michael E. DeBakey VAMC – Conroe and Lufkin 

Lufkin and Conroe CBOCs only had eight patients (three at Lufkin and five at Conroe) 

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

Fee Basis Justification. Conroe CBOC providers did not document a justification for 

four of five Fee Basis consults in CPRS. 

Patient Consult Notifications. The Conroe and Lufkin CBOCs did not notify any of the 

patients in writing of the consult approvals. 

Consult Approval Process. At the Lufkin CBOC, one of three consults was not 

approved as required by policy. 

9 VHA Handbook 1160.01.
 9 VHA Chief Business Office Policy 1601F.
 9 VHA Handbook 1907.01.
 9 VHA Manual M-1, PART I, Chapter 18.

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

VA OIG Office of Healthcare Inspections 7 
Branson, Harrison, Conroe, Lufkin, Hammond, and Houma 

Medical Record. At the Lufkin CBOC, a copy of the Short-Term Fee Basis imaging 

report was not found in one of three electronic medical records. 

VISN 16, Southeast Louisiana Veterans HCS – Hammond and Houma 

Policy. The Southeast Louisiana Veterans HCS did not have a local policy for 

Short-Term Fee Basis consults. 

Fee Basis Justification. We reviewed the medical records of 65 patients at the 

Hammond and Houma CBOCs (35 at Hammond and 30 at Houma) and found that 

providers at both CBOCs did not document a justification for any of the consults in 

CPRS. 

Patient Consult Notifications. We reviewed the medical records of 65 patients at the 

Hammond and Houma CBOCs and found that 60 (92 percent) patients were not notified 

in writing of consult approvals, and notifications were not documented in CPRS. 

Communication of Results. We reviewed the medical records of 65 patients at the 

Hammond and Houma CBOCs and found that 12 (18 percent) did not have evidence 

that the patient was 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.15 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 Measures16 

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

with approximately 207,000 new cases reported each year.17 Timely screening, 

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

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

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

20–30 percent among women age 40 and older. 

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

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

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

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

the under-representation of cases from large sites. It corrects for the unequal number of available cases within each
 

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

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

which cases pass or fail a measure. Sometimes the adjustment can be quite significant.
 17 American Cancer Society, Cancer Facts & Figures 2009.
 

VA OIG Office of Healthcare Inspections 8 
Branson, Harrison, Conroe, Lufkin, Hammond, and Houma 

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

respective CBOC’s scores. 

Measure 

Meets 

Target Facility 

Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 

(%) 

Mammography, 

50-69 years old 

77% 564 Veterans HCS of the 

Ozarks 

24 28 89 

564GC Branson CBOC 27 29 93 

564GA Harrison CBOC 15 15 100 

580 Michael E. DeBakey 

VAMC 

18 24 76 

580GD Conroe CBOC 22 30 73 

580BZ Lufkin CBOC 22 29 76 

629 Southeast Louisiana 

Veterans HCS 

27 27 100 

629GB Hammond CBOC 19 20 95 

629GA Houma CBOC 16 18 89 

Table 6. Mammography Screening FY 2011 

Conroe and Lufkin. To address mammography PM scores below the target 77 percent, 

the Lufkin and Conroe CBOCs are re-educating all primary care, women’s health, and 

fee basis staff on the mammogram requirements for women age 50-69. The CBOCs 

are also developing a process to distribute monthly reports of mammograms due to the 

Patient Aligned Care Team model to ensure timely performance of mammograms. 

Monthly status reports will also be forwarded to the Women Veterans Program Manager 

and Primary Care Director. Performance Improvement activities will be initiated as 

appropriate. 

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.18 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. 

18 VHA Handbook 1330.01. 

VA OIG Office of Healthcare Inspections 9 
Branson, Harrison, Conroe, Lufkin, Hammond, and Houma 

Noncompliant Areas Reviewed 

Patients are referred to mammography facilities that have current 

Food and Drug Administration or State-approved certifications. 

There is evidence that mammography is monitored as part of the 

facility’s quality management program. 

Mammogram results are documented using the American College 

of Radiology’s BI-RADS [Breast Imaging Reporting and Data 

System] code categories.19 

The ordering VHA provider or surrogate was notified of abnormal or 

critical results within a defined timeframe. 

Patients with abnormal or critical results are notified within a defined 

timeframe. 

Lufkin Patients receive written notice of normal mammogram results, and 

the notifications are documented in the patients’ medical record as 

required by VHA policy.20 

The facility has an established process for tracking results from 

mammograms performed off-site. 

Fee Basis mammography reports are scanned into CPRS. 

Conroe 

Lufkin 

All screening and diagnostic mammograms were initiated via an 

order placed into the VistA Radiology package.21 

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 16, Michael E. DeBakey VAMC – Conroe and Lufkin 

Notice of Results. At the Lufkin CBOC, five of seven patients did not have documented 

notice of mammogram results. 

Mammography Orders and Access. Conroe and Lufkin CBOC providers did not 

consistently (7 of 10) enter mammogram radiology orders for fee basis mammograms in 

CPRS. We also found that not all breast imaging results were linked to the appropriate 

radiology mammogram or breast study order. 

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.22 We reviewed nurse personnel files to ensure licensure and education was 

19 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.

20 VHA Handbook 1330.01.
 21 VHA Handbook 1330.01.
 22 VHA Handbook 1100.19.
 

VA OIG Office of Healthcare Inspections 10 
Branson, Harrison, Conroe, Lufkin, Hammond, and Houma 

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. 

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. 

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

Houma Committee list documents reviewed and the rationale for 

conclusions reached for granting licensed independent practitioner 

privileges. 

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

Lufkin specific.23 

Hammond 

Houma 

The determination to continue current privileges are based in part 

on results of OPPE activities. 

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 service and provider specific. 

There is documentation that the nurses’ licenses were verified. 

There is evidence that the nurses’ education was verified. 

Table 8. C&P 

VISN 16, Michael E. DeBakey VAMC – Conroe and Lufkin 

Clinical Privileges. The PSB granted clinical privileges for procedures such as 

emergency cardioversion, emergency endotracheal intubation, and thoracentesis, which 

were not performed at either CBOC. 

23 VHA Handbook 1100.19. 

VA OIG Office of Healthcare Inspections 11 
Branson, Harrison, Conroe, Lufkin, Hammond, and Houma 

VISN 16, Southeast Louisiana Veterans HCS – Hammond and Houma 

Clinical Privileges. The PSB granted clinical privileges for procedures such as lumbar 

punctures, paracentesis, and thoracentesis, which were not performed at either CBOC. 

Documentation of Privileging Decisions. We reviewed six licensed independent 

practitioners at the Hammond and Houma CBOCs and did not find documentation in the 

service chief’s comments in VetPro that reflected the documents used to arrive at the 

decision to grant clinical privileges to the providers. According to VHA policy, the list of 

documents reviewed and the rationale for conclusions reached by the service chief 

must be documented in VetPro.24 

Skills Competency 

The Joint Commission 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 

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

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

The policy defines who is responsible for competency validation and 

what the process is for selection of qualified personnel to assess 

and validate competence. 

The CBOC has a policy or process describing actions taken when 

staff cannot demonstrate competency. 

The facility has identified skill competencies for the CBOC. 

Staff competency was initially assessed and documented as a part 

of the CBOC orientation. 

Patient care staff identified skill competencies were validated and 

documented. 

Table 9. Skills Competency 

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

recommendations. 

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. 

24 VHA Handbook 1100.19. 

VA OIG Office of Healthcare Inspections 12 
Branson, Harrison, Conroe, Lufkin, Hammond, and Houma 

Noncompliant Areas Reviewed 

There is handicap parking which meets the ADA requirements. 

The CBOC entrance ramps meet ADA requirements. 

The entrance door to the CBOC meets ADA requirements. 

The CBOC is well maintained (i.e., 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). 

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

areas as identified by the vulnerability risk assessment. 

Hammond Privacy is maintained. 

Houma IT security rules are adhered to. 

Conroe 

Hammond 

Houma 

Patients’ PII is secured and protected. 

There are alcohol hand wash or soap dispensers and sinks 

available in examination rooms. 

The sharps containers are less than 3⁄4 full. 

There is evidence of fire drills occurring at least annually. 

Houma Fire extinguishers are easily identifiable. 

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

Staff use two patient identifiers for blood drawing procedures. 

The CBOC has signage for veterans (OIG Hotline, OEF/OIF 

returning veterans, women veterans, patient rights, and suicide 

hotline number). 

The CBOC is included in facility-wide EOC activities. 

Table 10. EOC 

VISN 16, Michael E. DeBakey VAMC – Conroe 

PII. The Conroe CBOC utilized a community volunteer to telephone patients and 

remind them of upcoming appointments. The community volunteer had access to 

patients’ PII. The CBOC did not have documentation to show that the volunteer had 

received required annual privacy awareness training. Local policy requires that 

volunteers receive annual privacy awareness training. 

VISN 16, Southeast Louisiana Veterans HCS – Hammond and Houma 

IT Security. At the Houma CBOC, we inspected the IT closet and found other supplies 

(such as clerical and manuals). Additionally, an access log to this area was not 

maintained. Lack of oversight for IT space access and sharing of allocated IT space 

could lead to potential loss of secure information. According to VHA policy, an access 

log must be maintained that includes name and organization of the person visiting, 

VA OIG Office of Healthcare Inspections 13 
Branson, Harrison, Conroe, Lufkin, Hammond, and Houma 

signature of the visitor, form of identification, date of access, time of entry and 

departure, and purpose of visit.25 

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

process at the Hammond CBOC. VHA policy requires auditory privacy when staff 

discuss sensitive patient issues.26 At the Hammond CBOC, patients communicate with 

staff through two slide-open glass windows located in the waiting area. Patients are 

asked to provide, at a minimum, their name and full social security number. There were 

no instructions to incoming patients to allow patients at the window a zone of audible 

privacy during the check-in process. 

Life Safety. The Houma CBOC did not have signage to identify fire extinguishers 

located in recessed walls or stored in cabinetry. The National Fire Protection 

Association Life Safety Code requires identification of fire extinguisher locations when 

they are obscured from view. 

PII. We found that the transportation of laboratory specimens at the Hammond and 

Houma CBOCs were not secured. CBOC staff placed the specimens in unsecured 

containers. A VA driver transported the specimens to the parent facility for processing. 

The specimens disclosed the patient’s name and social security number, and the 

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

PII from theft or misuse. 

Emergency Management 

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

defining how medical emergencies, including MH, are handled.27 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. 

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 

25 VA Handbook 6500, Information Security Program, September 18, 2007. 26 VHA Handbook, Privacy and Release of Information, May 17, 2006. 27 VHA Handbook 1006.1. 

VA OIG Office of Healthcare Inspections 14 
 

Branson, Harrison, Conroe, Lufkin, Hammond, and Houma 

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

recommendations. 

PCMM 

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

accuracy of the primary care panels. VHA directive states that each patient must 

have only one assigned PCP within the VA system unless approval has been 

obtained for more than one provider.28 

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

needed improvement. Details regarding the finding follow the table. 

Noncompliant Areas Reviewed 

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

being seen for their first appointment. 

Branson The facility has an enrollment process to ensure patients are 

assigned to one PCP (excluding VHA exceptions). 

Patients are identified for removal from the PCMM panel on a 

monthly basis (at a minimum) and panels are current. 

Panel sizes are reasonable compared to the PCMM guidelines. 

The number of patients invoiced is comparable to the total number 

of patients assigned to the PCP panels. 

Table 12. PCMM 

VISN 16, Veterans HCS of the Ozarks − Branson CBOC 

PCP Panel. The Veterans HCS of the Ozarks had approximately 47,200 active 

patients, with approximately 4,000 assigned to the Branson CBOC. There were 

approximately 230 patients assigned to a Branson PCP in PCMM that were also 

assigned to an additional PCP at other facilities. The additional assignments were 

not approved. 

CBOC Contract 

We conducted reviews of primary care and contracted MH services performed at the 

contract CBOCs to evaluate the effectiveness of VHA oversight and administration for 

selected contract provisions relating to quality of care and payment of services. Each 

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

encounter data, (3) corroboration of information with VHA data sources, (4) site visits, 

and (5) interviews with VHA and contractor staff. Our review focused on documents 

and records for the 1st Qtr, FY 2011. 

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

VA OIG Office of Healthcare Inspections 15 
 

Branson, Harrison, Conroe, Lufkin, Hammond, and Houma 

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

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

Noncompliant Areas Reviewed 

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

Houma a. Requirements for payment. 

Harrison b. Rate and frequency of payment. 

Harrison 

Houma 

c. Invoice format. 

d. Performance measures (including incentives/penalties). 

Houma e. Billing the patient or any other third party. 

(2) Technical review of contract modifications and extensions. 

Harrison 

Houma 

(3) Invoice validation process. 

(4) The COTR designation and training. 

(5) Contractor oversight provided by the COTR. 

(6) Timely access to care. 

Table 13. Review of PC and MH Contract Compliance 

VISN 16, Veterans HCS of the Ozarks − Harrison CBOC 

Rate and Frequency of Payment. Section B.3 of the contract, Special Contract 

Requirements, Paragraph 12, Optional Item-Laboratory/Radiology Services for 

Non-Enrollees, specifies that some patients who receive their primary care at the 

Veterans HCS of the Ozarks may get laboratory work and radiology procedures done at 

the CBOC. The Schedule of Costs section of the contract includes pricing for a limited 

number of identified laboratory tests and radiology procedures. However, the contract 

provision does not limit the laboratory tests and radiology procedures to those listed in 

the Schedule of Costs, and the contract does not include the reimbursement rate for all 

laboratory tests performed for non-enrolled veterans. In addition, the contract does not 

specify a process for referring or approving non-enrolled patients to the CBOC for these 

tests or procedures. 

Invoice Format. The invoices are not in the format described in the contract, which 

requires that monthly invoices contain supporting data for the following three categories: 

(1) total number of enrolled patients from previous month’s invoice, (2) new patients 

enrolled since previous month’s invoice, and (3) disenrolled patients since previous 

month’s invoice. This format enables a more efficient invoice validation process and 

can serve as a monthly reconciliation. In addition, there is no provision in the contract 

regarding invoicing requirements for laboratory tests and radiology procedures 

performed for non-enrollees. 

Invoice Validation Process. The current invoice validation process involves a manual 

verification of each billed patient, which is time intensive and subject to error. The 

invoice validation process could be performed more efficiently by presenting the 

contractor with an electronic list of patients eligible for billing prepared from VA data. 

VA OIG Office of Healthcare Inspections 16 
 

Branson, Harrison, Conroe, Lufkin, Hammond, and Houma 

VISN 16, Southeast Louisiana Veterans HCS − Houma CBOC 

Requirements for Payment. We found that not all contract terms were clearly defined 

for requirements of payments for patients receiving contracted primary care and MH 

services at the Houma CBOC. 

Primary Care 

The contract definition of enrollment includes the statement “paid enrollment will occur 

when a patient has an assignment to a primary care provider panel at the CBOC 

location and at least one completed vesting encounter annually;” however, it does not 

define a vesting encounter. The contractor and Southeast Louisiana Veterans HCS 

agreed that a vesting encounter (or visit) was required for primary care; however, 

Southeast Louisiana Veterans HCS was not validating the invoice based on a vesting 

visit, and it was not clear which encounter codes qualified for vesting. 

Mental Health 

The contract does not state how long after the patient’s last visit the contractor is to 

receive the monthly capitated rate. The contractor and Southeast Louisiana Veterans 

HCS stated that as long as the patient is seen by the provider, the contractor was to be 

paid. Disenrollment from MH services was interpreted the same as primary care 

services but was not clearly stated in the contract. 

Invoice Validation Process. The invoice validation process did not include verifying that 

a patient had a vesting visit. Therefore, the contractor was compensated for patients 

that did not qualify for payment. The resulting overpayments for these patients were 

approximately $8,600 for the months of October, November, and December 2010. 

Invoice Format. The invoices are not in the format described in the contract, which 

requires that monthly invoices contain supporting data for the following three categories: 

(1) total number of enrolled patients from previous month’s invoice, (2) new patients 

enrolled since previous month’s invoice, and (3) disenrolled patients since previous 

month’s invoice. This format enables a more efficient invoice validation process and 

can serve as a monthly reconciliation. 

Billing the Patient or Any Other Third Party. We noted that the CBOC contract does not 

contain a provision that states the contractor is prohibited from billing the patient or any 

other third party while the patient is enrolled at the CBOC. This provision should be 

included in the contract to clearly communicate the expectation that payment from the 

VA for services provided to enrolled patients is to be considered payment in full. 

VA OIG Office of Healthcare Inspections 17 
Branson, Harrison, Conroe, Lufkin, Hammond, and Houma 

Appendix A 

VISN 16 Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: June 21, 2011 

From: Director, VISN 16 (10N16) 

Subject: CBOC Reviews: Branson, MO and Harrison, AR; Conroe 

and Lufkin, TX; and Hammond and Houma, LA 

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

Director, Management Review Services (VHA 10A4A4) 

Attached is the response to the above subject report. I have 

reviewed the responses and concur. If you have any 

questions, please contact Mary Jones at 601-206-6974. 

(original signed by:)
 

George H. Gray, Jr.
 

VA OIG Office of Healthcare Inspections 18 
Branson, Harrison, Conroe, Lufkin, Hammond, and Houma 

Appendix B 

Veterans HCS of the Ozarks Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: June 17, 2011
 

From: Director, Veterans HCS of the Ozarks (564/00)
 

Subject: CBOC Review: Branson, MO and Harrison, AR
 

To: Director, VISN 16 (10N16)
 

Attached is the Veterans Health Care Systems of the Ozarks 

response to the April CBOC Draft Report. 

(original signed by Johnny R. Henley, M.D.:) 

KATHLEEN R. FOGARTY 

VA OIG Office of Healthcare Inspections 19 
Branson, Harrison, Conroe, Lufkin, Hammond, and Houma 

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 PCMM Coordinator’s duties are 

performed in accordance with VHA policy to reduce the number of veterans assigned to 

more than one PCP. 

Concur 

Specific Corrective Action: Data reports were run to identify the patients that are 

enrolled at both the Branson, MO CBOC and other facilities within our system. Many of 

the patients have been discharged from the duplicate PCP. Continued correction is 

ongoing; however, the required PCMM reports to correct the duplicate enrollments were 

temporarily disabled the week of June 6, 2011. Nationally, the reports are under 

revision. VHSO will continue the correction as soon as the PCMM reports are released. 

Target date for completion: 8/30/11 pending the timely re-opening of the PCMM 

Reports capability. 

Recommendation 2. We recommended that the Contracting Officer ensures that all 

ancillary charges are defined, specifically all laboratory test reimbursement rates. 

Concur 

Specific Corrective Action: A contract modification will be negotiated and executed that 

will specify the process for referring/approving non-enrollees to obtain tests at the 

Harrison CBOC. The process will require the referring provider or designee to schedule 

the non-enrollee’s appointment for the specific Laboratory/Radiology procedure to be 

performed at the Harrison CBOC. The contract modification will also clarify that the 

current listing in the contract of tests available to non-enrollees is not all-inclusive and 

additional tests that the Harrison CBOC is capable of performing may be performed 

upon approval (per the process specified above). Lastly, the contract modification will 

specify that additional tests approved and performed for non-enrollees shall be 

reimbursed at the current Medicare rate. 

Target date for completion: July 31, 2011 

Recommendation 3. We recommended that the Facility Director ensure that the 

provisions of the contract are enforced specifically adhering to the invoice format in the 

contract. 

Concur 

VA OIG Office of Healthcare Inspections 20 
Branson, Harrison, Conroe, Lufkin, Hammond, and Houma 

Specific Corrective Action: Per the OIG recommendation, the South Texas Veterans 

Health Care System (STVHCS), San Antonio, TX has been consulted regarding their 

invoice validation process. Luanna Oxford, Harrison, AR CBOC COTR met with Roger 

Roehl, STVHCS on June 7, 2011. Consultation regarding adoption of a similar invoice 

validation process to the STVHS one is ongoing, with the next scheduled telephone 

conference on June 20, 2011. 

Target date for completion: 7/31/11 

VA OIG Office of Healthcare Inspections 21 
Branson, Harrison, Conroe, Lufkin, Hammond, and Houma 

Appendix C 

Michael E. DeBakey VAMC Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: June 21, 2011 

From: Director, Michael E. DeBakey VAMC (580/00) 

Subject: CBOC Review: Conroe and Lufkin, TX 

To: Director, VISN 16 (10N16) 

I have reviewed the report and concur with the recommendations. Action 

plans have been implemented to comply with the recommendations. 

ADAM C. WALMUS
 

VA OIG Office of Healthcare Inspections 22 
Branson, Harrison, Conroe, Lufkin, Hammond, and Houma 

Comments to Office of Inspector General’s Report
 

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

to the Office of Inspector General’s report: 

OIG Recommendations 

Recommendation 4. We recommended that providers document a justification for the 

use of Short-Term Fee Basis care in the medical record at the Conroe CBOC. 

Concur 

Target date for completion: Completed 

Facility Response: Justification for the use of Short Term Fee Basis care has been 

added to the Fee Basis Consult template to facilitate provider documentation of the 

reason for the consult.
 

Recommendation 5. We recommended that the veterans receive written notification
 

when a Short-Term Fee Basis consult is approved and that the notification is
 

documented in the medical record at the Conroe and Lufkin CBOCs.
 

Concur 

Target date for completion: Completed 

Facility Response: A process has been established that when the Fee Basis consult is 

approved a notification letter is sent to the Veteran and documentation of the notification 

is entered into the medical record in the Fee Consult.
 

Recommendation 6. We recommended that the Short-Term Fee Basis consults are
 

approved by appropriate leadership or a designee in accordance with VHA policy at the
 

Lufkin CBOC.
 

Concur 

Target date for completion: Completed 

Facility Response: The delegation of authority has been updated by the Chief of Staff’s 

office to include the appropriate leadership or designee. 

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

reports are filed or scanned into CPRS at the Lufkin CBOC. 

Concur 

Target date for completion: July 22, 2011 

VA OIG Office of Healthcare Inspections 23 
Branson, Harrison, Conroe, Lufkin, Hammond, and Houma 

Facility Response: CBOC Administrative Officers will ensure the scanning into CPRS of 

reports of Short-Term Fee Basis care for those reports being received at the CBOC. 

For those reports which are received at the Michael E. DeBakey VAMC main facility, a 

process is being developed for the reports to be sent to the Health Information 

Management Section to be scanned into the medical record. The Chief of Staff’s office 

will develop procedures to ensure compliance. 

Recommendation 8. We recommended that managers establish a process to ensure 

patient notification of results is documented in the medical record at the Lufkin CBOC. 

Concur 

Target date for completion: July 22, 2011 

Facility Response: The Chief of Staff’s office will develop procedures to ensure that 

Fee Basis reports, received at the CBOC, are sent to the patient and the patient 

notification is documented in the medical record. For those reports received at the 

Michael E. DeBakey VAMC main facility, a process is being developed that when 

reports are received by Radiology, the consult will be closed which will alert the provider 

of the availability of the results. A notification letter will be sent to the patient and the 

notification will be documented in the medical record. Other reports not received by 

Radiology, will be sent to the Health Information Management Section to be scanned 

into the medical record. Once the report is scanned into the medical record, the consult 

will be closed and the provider alerted of the availability of the results. A notification 

letter will be sent to the patient and the notification documented in the medical record. 

Recommendation 9. We recommended that managers establish a process to ensure 

CPRS mammogram radiology orders are entered for all fee basis and/or contract 

mammograms and that all breast imaging and mammography results are linked to the 

appropriate radiology mammogram or breast study order at the Conroe and Lufkin 

CBOCs. 

Concur 

Target date for completion: July 22, 2011 

Facility Response: A process is being developed to link the mammogram consult to an 

order for Fee Basis care and to link the results to the mammogram order both at all 

CBOCs and the main facility. The Chief of Staff’s office will develop a procedure to 

ensure compliance. 

Recommendation 10. We recommended that the PSB grants privileges consistent 

with the services provided at the Conroe and Lufkin CBOCs. 

Concur 

Target date for completion: August 19, 2011 

VA OIG Office of Healthcare Inspections 24 
Branson, Harrison, Conroe, Lufkin, Hammond, and Houma 

Facility Response: A generic list of privileges, appropriate for CBOC providers, is being 

developed. 

Recommendation 11. We recommended that all volunteers with access to PII receive 

and maintain annual privacy awareness training in accordance with local policy at the 

Conroe CBOC. 

Concur 

Target date for completion: Completed 

Facility Response: Volunteer Services will forward training to volunteers annually for 

completion. Administrative Officers will ensure completion of the training annually. 

VA OIG Office of Healthcare Inspections 25 
Branson, Harrison, Conroe, Lufkin, Hammond, and Houma 

Appendix D 

Southeast Louisiana Veterans HCS Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: June 9, 2011 

From: Director, Southeast Louisiana Veterans HCS (629/00) 

Subject: CBOC Reviews: Hammond and Houma, LA 

To: Director, VISN 16 (10N16) 

In response to the VISN 16 April CBOC Draft Report, the Southeast 

Louisiana Veterans Health Care System submits the attached comments 

as per instruction. 

(original signed by:) 

Jimmy Murphy, Acting Director 

VA OIG Office of Healthcare Inspections 26 
Branson, Harrison, Conroe, Lufkin, Hammond, and Houma 

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 12. We recommended that the facility develops a local policy for 

Short-Term Fee Basis consults. 

Concur 

Target date for completion: July 30, 2011 

Currently there is a draft policy for Short-Term Fee Basis consults. Business Office 

Operations is readying this policy to send to the policy review group for preliminary 

review prior to sending to NM Executive Group for approval. 

Recommendation 13. We recommended that providers document a justification for the 

use of Short-Term Fee Basis care in the medical record at the Hammond and Houma 

CBOCs. 

Concur 

Target date for completion: June 30, 2011 

The requirement for justification for Short-Term Fee Basis has been added into selected 

templates in CPRS. Short-Term Fee Basis for Radiology procedures that must be sent 

out remains a challenge because the decision to fee the procedure is made by 

Radiology on the basis of availability of resources within our Radiology Department. 

Currently the Clinical Applications Coordinators are adding to the Radiology request for 

these procedures a statement that will justify the procedure for Short-Term Fee Basis if 

the resource is not available at the New Orleans Radiology site. 

Recommendation 14. We recommended that the veterans receive written notification 

when a Short-Term Fee Basis consult is approved and that the notification is 

documented in the medical record at the Hammond and Houma CBOCs. 

Concur 

Target date for completion: July 30, 2011 

Business Office Operations is in the process of retraining Consult Management staff to 

send out fee letters once the authorization has been approved. Once the authorization 

is approved a letter is generated for the patient. Staff will mail the letters daily. 

VA OIG Office of Healthcare Inspections 27 
Branson, Harrison, Conroe, Lufkin, Hammond, and Houma 

Recommendation 15. We recommended that the ordering practitioners, or surrogate 

practitioners communicate the Short- Term Fee Basis consult results to the patient 

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

Hammond and Houma CBOCs. 

Concur 

Target date for completion: July 30, 2011 

All primary care providers have been notified of and/or re-educated to the requirement 

for notification of Short-Term Fee Basis consult results to the patient within 14 days. 

A&PC will audit all Short-Term Fee Basis consults that were resulted during the dates 

7/1/2011 – 7/31/2011 ordered by providers in the Houma and Hammond CBOCs to 

assure that notification of patients is accomplished per VHA Directive. 

Recommendation 16. We recommended that the PSB grants privileges consistent 

with the services provided at the Hammond and Houma CBOCs. 

Concur 

Target date for completion: June 30, 2011 

The Associate Chief of Staff/Clinics is requesting modification of current clinical 

privileges to remove the following procedures: contrast injection, lumbar puncture, 

paracentesis and thoracentesis from all CBOCs. This recommendation will be 

presented at the next Physician Standards Board (PSB) meeting that is to be held June 

20, 2011. The above procedures will be removed from clinical privileges once the 

governing body (Director) approves the recommendation. 

Recommendation 17. We recommend that the service chief’s documentation in 

VetPro reflects documents reviewed and the rationale for privileging or re-privileging at 

the Hammond and Houma CBOCs. 

Concur 

Target date for completion: Completed 

On April 13, 2011 a notice was sent to all service chiefs reminding them to adhere to 

VHA policy and ensure that documentation in the service chief’s comments in VETPro 

reflects the documents used to arrive at the decision to grant clinical privileges to the 

provider. To ensure that this requirement is enforced, the Chief of Staff will review all 

Service Chief Assessments and will not bring applications forward for consideration by 

PSB unless the Service Chief Assessments include the required documentation. 

Recommendation 18. We recommended that the Chief of Office of Information & 

Technology evaluates the use of the information technology closet and implement 

appropriate measures according to VA policy at the Houma CBOC. 

VA OIG Office of Healthcare Inspections 28 
Branson, Harrison, Conroe, Lufkin, Hammond, and Houma 

Concur 

Target date for completion: Completed 

A binder with access list and sign in/out sheets for authorized staff and visiting 

individuals is located at each communication closet. The key to the communication 

closet is given out by Police and Security with approval from the Facility chief 

Information officer. The action has been remediated and the communication closet has 

all necessary documentation in place as of June 2, 2011. In addition, as of June 6, 

2011, the key to the communications closet in Houma was surrendered to the Chief of 

Police and access is now per policy in Houma CBOC. 

Recommendation 19. We recommended that the auditory privacy is maintained during 

check-in process at the Hammond CBOC. 

Concur 

Target date for completion: September 30, 2011 

There is a plan to construct a wall in Room 101 in Hammond to separate the 

receptionist/check-in area into two small offices. The front reception windows would be 

replaced with glass doors to provide patient access. We estimate this project would 

cost about $16,500 and would be done under a station project. 

Recommendation 20. We recommended installation of signage to identify the location 

of fire extinguishers at the Houma CBOC. 

Concur 

Target date for completion: Completed 

Fire extinguisher signage has been installed in Houma by VALOR. 

Recommendation 21. We recommend that the security of patient PII is maintained at 

the Hammond and Houma CBOCs. 

Concur 

Target date for completion: Completed 

In order to protect the patient identifiable information (PII) on lab specimens while in 

transit from the point of specimen collection to the receiving laboratory, lab specimen 

transport containers will be secured with tamper proof, locking straps. These locking 

straps will secure the lids of the containers so that the containers will not open in transit. 

The locking straps will be applied to the containers at the point of specimen collection 

and will not be removed until the containers are received at the destination laboratory. 

At the destination laboratory an audit will be conducted to verify that no specimens are 

missing or were removed from the container during transport. This enhanced procedure 

VA OIG Office of Healthcare Inspections 29 
Branson, Harrison, Conroe, Lufkin, Hammond, and Houma 

will ensure the protection of PII including a process to detect if any PII might have been 

compromised in transit. 

Recommendation 22. We recommended that the Contracting Officer ensures that all 

contract terms are clearly defined for requirements of payments, specifically the term 

vesting encounter. 

Concur 

Target date for completion: September 2011 

The contract will be amended to clearly state the intent of Vesting. Business Office 

Operations will work with the contracting Office to amend the contract. 

Recommendation 23. We recommended that the Facility Director determines the total 

amount of overpayments to the contractor during the contract period as a result of 

ineligible patients and, with the assistance of the Regional Counsel, assess the 

collectability of the overpayment. 

Concur 

Target date for completion: July 30, 2011 

Business office Operations is working with DSS to review all invoices from October 

2010 through June 2011 to ensure enrollment has met the requirements of a vesting 

appointment in order to receive payment. BOO [Business Office Operations] will work 

with fiscal and contracting to generate a bill of collection on any overpayments. 

Recommendation 24. We recommended that the Facility Director ensures that the 

provisions of the contract are enforced, specifically the invoice format in the contract. 

Concur 

Target date for completion: Completed 

The contractor has been notified of the need to follow the correct format as stated in the 

contract or the invoice will be rejected. 

VA OIG Office of Healthcare Inspections 30 
Branson, Harrison, Conroe, Lufkin, Hammond, and Houma 

Appendix E 

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 

Sheila Bezak, RN 

Shirley Carlile, BA 

Marisa Casado, RN 

Lin Clegg, PhD 

Marnette Dhooghe, MS 

Nathan Fong, CPA 

Stephanie Hensel, RN, JD 

Stephanie Hills, RN 

Zhana Johnson, CPA 

Sandra Khan, RN 

Anthony M. Leigh, CPA 

Jennifer Reed, RN 

Thomas J. Seluzicki, CPA 

Marilyn Stones, BS 

Ann Ver Linden, RN 

Cheryl Walker, NP 

VA OIG Office of Healthcare Inspections 31 
Branson, Harrison, Conroe, Lufkin, Hammond, and Houma 

Appendix F 

Report Distribution 

VA Distribution 

Office of the Secretary
 

Veterans Health Administration
 

Assistant Secretaries
 

General Counsel
 

Director, VISN 16 (10N16)
 

Director, Veterans HCS of the Ozarks (564/00)
 

Director, Michael E. DeBakey VAMC (580/00)
 

Director, Southeast Louisiana Veterans HCS (629/00)
 

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: Roy Blunt, John Boozman, John Cornyn, Kay Bailey Hutchison, 

Mary L. Landrieu, Claire McCaskill, Mark L. Pryor, David Vitter 

U.S. House of Representatives: Kevin Brady, Louie Gohmert, Jeffrey M. Landry, Billy 

Long, Steve Scalise, Steve Womack 

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

VA OIG Office of Healthcare Inspections 32