Department of Veterans Affairs 

Office of Inspector General 

Office of Healthcare Inspections
 

Report No. 11-01406-238 

Community Based Outpatient
 

Clinic Reviews
 

Bradford (McKean County) and
 

Franklin (Venango County), PA
 

Camp Hill and Pottsville/Frackville, PA
 

Mission, SD and Newcastle, WY
 

Hibbing and Rochester, MN
 

July 29, 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) 
McKean, Venango, Camp Hill, Pottsville/Frackville, Mission, Newcastle, Hibbing, and Rochester 

Glossary
 AED automated external defibrillator 

C&P credentialing and privileging 

CBOC community based outpatient clinic 

COTR Contracting Officer’s Technical Representative 

CPRS Computerized Patient Record System 

CT Computerized Tomography 

DX & TX Plan Diagnosis & Treatment Plan 

ED emergency department 

EKG electrocardiogram 

EOC environment of care 

FPPE Focused Professional Practice Evaluation 

FTE full-time employee equivalents 

FY fiscal year 

HCS Health Care System 

IT information technology 

JC Joint Commission 

LCSW Licensed Clinical Social Worker 

MedMgt medication management 

MH mental health 

MHICM mental health intensive case management 

MRI Magnetic Resonance Imaging 

MST military sexual trauma 

NP nurse practitioner 

OIG Office of Inspector General 

OPPE Ongoing Professional Practice Evaluation 

PA physician assistant 

PCMM Primary Care Management Module 

PCP primary care provider 

PET Positron Emission Tomography 

PII personally identifiable information 

PTSD Post-Traumatic Stress Disorder 

Qtr quarter 

TX treatment 

VAMC VA Medical Center 

VHA Veterans Health Administration 

VISN Veterans Integrated Service Network 

VistA Veterans Health Information Systems and Technology 

Architecture 

VA OIG Office of Healthcare Inspections 
McKean, Venango, Camp Hill, Pottsville/Frackville, Mission, Newcastle, Hibbing, and Rochester 

Table of Contents
 

Page
 

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

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

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

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

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

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

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

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

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

C&P ........................................................................................................................ 12
 

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

Environment and Emergency Management............................................................ 15
 

PCMM..................................................................................................................... 19
 

CBOC Contract....................................................................................................... 20
 

Appendixes 

A. VISN 4 Director Comments ............................................................................... 23
 

B. Erie VAMC Director Comments......................................................................... 24
 

C. Lebanon VAMC Director Comments ................................................................. 28
 

D. VISN 23 Director Comments ............................................................................. 35
 

E. VA Black Hills HCS Director Comments............................................................ 36
 

F. Minneapolis VA HCS Director Comments ......................................................... 42
 

G. OIG Contact and Staff Acknowledgments......................................................... 48
 

H. Report Distribution............................................................................................. 49
 

VA OIG Office of Healthcare Inspections 
McKean, Venango, Camp Hill, Pottsville/Frackville, Mission, Newcastle, Hibbing, and Rochester 

Executive Summary
 

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

May 16, 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 

4 Erie VAMC McKean County 

Venango County 

Lebanon VAMC Camp Hill 

Pottsville/Frackville 

23 VA Black Hills HCS Mission 

Newcastle 

Minneapolis VA HCS Hibbing 

Rochester 

Table 1. Sites Inspected 

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

respective CBOC managers, should take appropriate actions to: 

Erie VAMC 

	 Ensure Short-Term Fee Basis consults for the McKean County CBOC are approved 

by appropriate leadership or a designee in accordance with VHA and local policy. 

	 Ensure 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 McKean County CBOC. 

	 Ensure that the ordering practitioners, or surrogate practitioners, document in the 

medical record that they reviewed the Short-Term Fee Basis report at the McKean 

County CBOC. 

	 Ensure 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 McKean County CBOC. 

	 Install exit signage of material that illuminates to ensure that patients, visitors, and 

staff can exit safely during an emergency at the McKean County CBOC. 

	 Ensure that the doorbell is repaired at the McKean County CBOC. 

	 Ensure that the Contracting Officer prepares a contract modification to add a 

provision that prohibits the contractor from billing the patient or any other source for 

services that are covered under the VA primary care contract. 

VA OIG Office of Healthcare Inspections i 
McKean, Venango, Camp Hill, Pottsville/Frackville, Mission, Newcastle, Hibbing, and Rochester 

Lebanon VAMC 

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

	 Ensure 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 Camp Hill CBOC. 

	 Ensure that the ordering practitioners, or surrogate practitioners, document in the 

medical record that they reviewed the Short-Term Fee Basis report at the Camp Hill 

CBOC. 

	 Ensure 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 Camp Hill CBOC. 

	 Ensure that the parent Facility Director appoints a Women’s Health Liaison who 

collaborates with the parent facility’s Women Veterans Program Manager on 

women’s health issues for the patients at the Camp Hill and Pottsville/Frackville 

CBOCs. 

	 Establish a process to document patient notification results in the medical record at 

the Camp Hill and Pottsville/Frackville CBOCs. 

	 Ensure that the ordering providers at the Camp Hill and Pottsville/Frackville CBOCs 

enter all radiology orders for fee basis mammograms in CPRS and link breast 

imaging results to the radiology mammogram order. 

	 Compare practitioner data either to those practitioners doing similar procedures or to 

aggregated data of those privileged practitioners with the same or comparable 

privileges at the Camp Hill CBOC. 

	 Validate and document competencies for all patient care staff at the Camp Hill and 

Pottsville/Frackville CBOCs. 

	 Ensure that clean and dirty items at the Pottsville/Frackville CBOC (Pottsville 

campus) are stored according to VHA policy. 

	 Ensure that the Chief of OI&T evaluates the use of the IT closet and implements 

appropriate measures according to VA policy at the Pottsville/Frackville CBOCs. 

	 Ensure that a Hazard Vulnerability Assessment is conducted to determine if potential 

patient or environmental safety hazards exist at the Pottsville/Frackville CBOC 

(Pottsville campus). 

	 Secure the transportation of laboratory specimens at the Camp Hill and 

Pottsville/Frackville CBOCs. 

VA OIG Office of Healthcare Inspections ii 
McKean, Venango, Camp Hill, Pottsville/Frackville, Mission, Newcastle, Hibbing, and Rochester 

	 Maintain auditory privacy during the check-in process at the Camp Hill and 

Pottsville/Frackville CBOCs. 

	 Ensure the appropriate measures are in place to maintain patient privacy at the 

Pottsville/Frackville CBOC (Pottsville campus). 

	 Ensure an AED is available at the Pottsville/Frackville CBOC (Pottsville campus). 

	 Ensure that the Contracting Officer prepares a contract modification to add a 

provision that prohibits the contractor from billing the patient or any other source for 

services that are covered under the VA primary care contract. 

	 Require that the Facility Director and Contracting Officer ensure that contracted 

primary care providers are aware of ethics rules regarding self-referral and are free 

of any conflicts of interest. 

	 Require that the Facility Director and Contracting Officer ensure that contract 

provisions are written and enforced to ensure proper payment specifically as they 

relate to patient disenrollment, vesting visits, VistA notes, and means tests. 

VA Black Hills HCS 

	 Develop a plan for the Mission and Newcastle CBOCs that defines how MH 

emergencies that require a higher level of care are addressed. 

	 Establish a process to ensure timely notification to patients of mammography results 

and that this process is monitored for ongoing compliance at the Newcastle CBOC. 

	 Ensure that the Mission CBOC identifies a Women’s Health Liaison and that 

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

	 Ensure that OPPEs include clinically pertinent data as well as performance 

measures compliance at the Mission and Newcastle CBOCs. 

	 Require that relevant provider-specific data be compared to aggregated data of 

those privileged providers who hold the same or comparable privileges at the 

Mission and Newcastle CBOCs. 

	 Require that scopes of practice are provider-specific, service-specific, and 

facility-specific at the Newcastle CBOC. 

	 Ensure that staff receive training for required skill competencies and that this training 

is validated and documented at the Mission and Newcastle CBOCs. 

	 Ensure that all patient care staff members are assessed at orientation and annually 

to assure competence to perform their responsibilities for Mission and Newcastle 

CBOCs. 

VA OIG Office of Healthcare Inspections iii 
McKean, Venango, Camp Hill, Pottsville/Frackville, Mission, Newcastle, Hibbing, and Rochester 

	 Conduct annual fire drills at the Newcastle and Mission CBOCs. 

	 Monitor and collect measurable data for hand hygiene at the Newcastle and Mission 

CBOCs. 

	 Conduct a vulnerability risk review to assess the need for panic alarms at the 

Newcastle and Mission CBOCs. 

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

the Mission CBOC. 

	 Develop a local policy or SOP for medical and MH emergencies that reflects the 

current practice and capability at the Mission and Newcastle CBOCs. 

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

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

	 Require that the Facility Director and Contracting Officer ensure the contractor 

complies with the required contract reporting provisions. 

Minneapolis VA HCS 

	 Ensure that a contract, sharing agreement, or other appropriate arrangement is 

developed with the external organization for sharing information when patients at the 

Hibbing and Rochester CBOCs are referred to a community-based ED for MH 

emergencies. 

	 Document a justification for the use of Short-Term Fee Basis care in the medical 

record at the Rochester CBOC. 

	 Ensure that the veteran receives written notification when a Short-Term Fee Basis 

consult is approved and that the notification is documented in the system of record 

at the Rochester CBOC. 

	 Ensure that the copies of Short-Term Fee Basis mammography reports of Rochester 

CBOC patients are filed or scanned into the radiology package in the medical 

record. 

	 Require that managers at the Hibbing and Rochester CBOCs establish a process to 

ensure effective oversight of the mammography program as required by VHA policy. 

	 Establish a process to ensure that all mammogram orders are entered into the 

CPRS radiology package and that all mammography results are linked to the 

appropriate order at the Hibbing and Rochester CBOCs. 

	 Enter mammography results in BI-RADS [Breast Imaging Reporting and Data 

System] categories at the Hibbing and Rochester CBOCs. 

VA OIG Office of Healthcare Inspections iv 
McKean, Venango, Camp Hill, Pottsville/Frackville, Mission, Newcastle, Hibbing, and Rochester 

	 Ensure that the Professional Standards Board grants privileges consistent with the 

services provided at the Hibbing CBOC. 

	 Ensure that service-specific competency criteria is created, approved, and 

implemented in advance of the start of the FPPE period for providers at the Hibbing 

and Rochester CBOCs. 

	 Require that all providers have a scope of practice that is provider-specific, 

service-specific, and facility-specific. 

	 Ensure that all patient care staff members’ identified skill competencies are 

assessed annually to assure competence to perform their responsibilities at the 

Rochester CBOC. 

	 Conduct and document fire drills annually at the Rochester CBOC. 

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

enrollment upon completion of the patient’s appointment and reduce the number of 

veterans assigned to more than one PCP. 

	 Require that the Facility Director strengthens the invoice validation process to 

ensure the invoiced enrollees using VA data and provide that list of billable enrollees 

to the contractor. This process mitigates the risk of overpayments to the contractor. 

	 Ensure that the Facility Director and Contracting Officer modify the contract to 

comply with VHA policies. 

Comments 

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

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

pages 23–47 for the full text of the Directors’ comments.) We will follow up on the 

planned actions until they are completed. 

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

Assistant Inspector General for
 

Healthcare Inspections
 

VA OIG Office of Healthcare Inspections v 
McKean, Venango, Camp Hill, Pottsville/Frackville, Mission, Newcastle, Hibbing, and Rochester 

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 
McKean, Venango, Camp Hill, Pottsville/Frackville, Mission, Newcastle, Hibbing, and Rochester 

 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 
McKean, Venango, Camp Hill, Pottsville/Frackville, Mission, Newcastle, Hibbing, and Rochester 

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

CBOCs and specific characteristics. 

McKean 

County 

Venango 

County 

Camp Hill Pottsville/ 

Frackville 

Mission Newcastle Hibbing Rochester 

VISN 4 4 4 4 23 23 23 23 

Parent Facility Erie VAMC Erie VAMC Lebanon VAMC Lebanon VAMC Black Hills 

HCS 

Black Hills 

HCS 

Minneapolis 

VAMC 

Minneapolis 

VAMC 

Type of CBOC Contract VA VA Contract Contract VA Contract VA 

Number of 

Uniques,5 FY 

2010 

1,204 1,916 8,819 2,661 166 97 3,197 3,473 

Number of 

Visits, FY 2010 

3,506 6,470 40,652 5,361 527 224 7,863 11,341 

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

Locality Rural Rural Urban Rural Rural Highly Rural Rural Rural 

FTE PCP 1 1.6 7.61 2.25 0.2 0.1 3.5 3.71 

FTE MH 0 1 7 0.4 0 1 2 2 

Types of 

Providers 

PCP PCP 

NP 

PCP 

NP 

PA 

Psychiatrist 

Psychologist 

LCSW 

PCP 

NP 

PA 

Psychiatrist 

PA NP PCP 

NP 

Psychiatrist 

Psychologist 

LCSW 

PCP 

NP 

PA 

Psychiatrist 

Psychologist 

LCSW 

Specialty Care 

Services Onsite 

No No Yes No No No No Yes 

Tele-Health 

Services 

None Tele-Medicine 

Tele-Retinal 

Tele-Dietary 

None None None None Tele-Medicine Tele-Medicine 

Ancillary 

Services 

Provided Onsite 

Laboratory 

EKG 

Laboratory 

EKG 

Laboratory 

PT/OT 

EKG 

Laboratory 

EKG 

Laboratory Laboratory Laboratory 

EKG 

Laboratory 

EKG 

Satellite Clinic None None None None None None Cook VA Clinic 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 
McKean, Venango, Camp Hill, Pottsville/Frackville, Mission, Newcastle, Hibbing, and Rochester 

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 to 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 
McKean, Venango, Camp Hill, Pottsville/Frackville, Mission, Newcastle, Hibbing, and Rochester 

Mental Health CBOC Characteristics 

McKean 

County 

Venango 

County 

Camp Hill Pottsville/ 

Frackville 

Mission Newcastle Hibbing Rochester 

Provides MH 

Services 

No Yes Yes Yes No Yes Yes Yes 

Number of MH 

Uniques, FY 

2010 

0 186 1,805 132 0 11 378 626 

Number of MH 

Visits 

0 957 8,552 401 0 26 2,726 2,632 

General MH 

Services 

NA Dx & TX Plan 

MedMgt 

Psychotherapy 

PTSD 

MST 

Dx & TX Plan 

MedMgt 

Psychotherapy 

PTSD 

MST 

Dx & TX Plan 

MedMgt 

PTSD 

MST 

NA Dx & TX Plan Dx & TX Plan 

MedMgt 

Psychotherapy 

PTSD 

MST 

Dx & TX Plan 

MedMgt 

Psychotherapy 

PTSD 

MST 

Specialty MH 

Services 

NA Consult & TX 

MHICM 

Homeless Prgm 

PTSD 

Substance Use 

Disorder 

None NA None Consult & TX 

Psychotherapy 

MHICM 

Psychosocial 

Rehab 

Social Skills 

PTSD 

Homeless Prgm 

Substance Use 

Disorder 

Consult & TX 

Psychotherapy 

PTSD 

Tele-Mental 

Health 

No Yes Yes No No No Yes Yes 

MH Referrals Another VA 

Facility 

Fee-Basis 

Another VA 

Facility 

Fee-Basis 

Another VA 

Facility 

Fee-Basis 

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 
McKean, Venango, Camp Hill, Pottsville/Frackville, Mission, Newcastle, Hibbing, and Rochester 

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 

Mission 

Newcastle 

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. 

Hibbing 

Rochester 

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 23, VA Black Hills HCS – Mission and Newcastle 

Emergency Plan. The Mission and Newcastle CBOCs did not have a plan identified in 

their local policy addressing how MH emergencies would be addressed during the hours 

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

VISN 23, Minneapolis VA HCS – Hibbing and Rochester 

Sharing Agreement. We did not find documentation that managers had developed 

contracts, sharing agreements, or other appropriate arrangements with the external 

organization for sharing information. The Hibbing and Rochester CBOCs designated 

community EDs for referral; however, they did not have a written plan as to how the 

information would be shared between the sites. 

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 

8 VHA Handbook 1160.01. 

VA OIG Office of Healthcare Inspections 6 
McKean, Venango, Camp Hill, Pottsville/Frackville, Mission, Newcastle, Hibbing, and Rochester 

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

transportation. 

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

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

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

improvement. Details regarding the findings follow the table. 

Noncompliant Areas Reviewed 

Camp Hill 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.9 

Rochester 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. 

McKean 

County 

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 

Camp Hill 

McKean 

County 

Rochester 

Patients were notified of consult approvals in writing, and 

notifications are documented in the patients' medical records as 

required by VHA policy.12 

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

Camp Hill 

McKean 

County 

There is evidence the ordering provider or surrogate practitioner 

reviewed the report. 

Camp Hill 

McKean 

County 

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 4, Erie VAMC – McKean County 

There were 15 patients at the McKean County CBOC and 6 patients at the Venango 

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

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 
McKean, Venango, Camp Hill, Pottsville/Frackville, Mission, Newcastle, Hibbing, and Rochester 

Consult Approval Process. We found at the McKean County CBOC that 8 of 

15 consults were not approved according to VHA and local policy. 

Patient Consult Notifications. We found at the McKean County CBOC that 9 of 

15 patients were not notified in writing of consult approvals, and the notifications were 

not documented in CPRS. 

Report Review. At the McKean County CBOC, we found no evidence in 3 of 15 medical 

records that the ordering provider or surrogate practitioner reviewed the report. 

Communication of Results. At the McKean County CBOC, we found no evidence in the 

medical record that 3 of the 15 patients were informed about the results within 

14 calendar days. 

VISN 4, Lebanon VAMC – Camp Hill and Pottsville/Frackville 

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

consult at the Camp Hill CBOC. No patients met the criteria for review at the 

Pottsville/Frackville CBOC. 

Policy. Lebanon VAMC did not have a local policy for Short-Term Fee Basis consults. 

Patient Consult Notifications. At the Camp Hill CBOC, we found no evidence in the 

medical records that the seven patients were notified in writing of the consult approvals. 

Report Review. At the Camp Hill CBOC, we found no evidence in three of seven 

medical records that the ordering provider or surrogate practitioner reviewed the report. 

Communication of Results. At the Camp Hill CBOC, we found no evidence in the 

medical records that five of the seven patients were informed about the results within 

14 calendar days. 

VISN 23, Minneapolis VA HCS – Rochester 

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

consult at the Rochester CBOC. No patients met the criteria for review at the Hibbing 

CBOC. 

Fee Basis Justification. The provider at the Rochester CBOC did not document a 

justification for the consult in CPRS. 

Patient Consult Notifications. The patient at the Rochester CBOC was not notified in 

writing of the consult approval. 

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

Basis imaging report in the medical record. 

VA OIG Office of Healthcare Inspections 8 
McKean, Venango, Camp Hill, Pottsville/Frackville, Mission, Newcastle, Hibbing, and Rochester 

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 

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% 562 Erie VAMC 17 19 89 

562GC McKean County 5 5 100 

562GD Venango County 12 12 100 

595 Lebanon VAMC 14 17 78 

595GA Camp Hill 25 30 83 

595GF Pottsville/Frackville 11 13 85 

568 VA Black Hills HCS 32 38 96 

568HJ Mission 0 0 NA 

568HA Newcastle 2 2 100 

618 Minneapolis VA HCS 19 26 67 

618GB Hibbing 12 14 86 

618GG Rochester 23 25 92 

Table 6. Mammography Screening FY 2011 

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. Weighting can alter the raw measure score
 

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

VA OIG Office of Healthcare Inspections 9 
McKean, Venango, Camp Hill, Pottsville/Frackville, Mission, Newcastle, Hibbing, and Rochester 

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. 

Noncompliant Areas Reviewed 

Patients are referred to mammography facilities that have current 

Food and Drug Administration or State-approved certifications. 

Hibbing 

Rochester 

Mammogram results are documented using the American College 

of Radiology’s BI-RADS code categories.19 

The ordering VHA provider or surrogate was notified of abnormal or 

critical results within a defined timeframe. 

Pottsville/ 

Frackville 

Patients with abnormal or critical results are notified within a defined 

timeframe. 

Camp Hill 

Pottsville/ 

Frackville 

Newcastle 

Patients receive written notice of normal mammogram results, and 

the notifications are documented in the patients’ medical record as 

required by VHA policy.20 

Hibbing 

Rochester 

The facility has an established process for tracking results from 

mammograms performed off-site. 

Fee Basis mammography reports are scanned into CPRS. 

Camp Hill 

Hibbing 

Pottsville/ 

Frackville 

Rochester 

All screening and diagnostic mammograms were initiated via an 

order placed into the VistA Radiology package.21 

Pottsville/ 

Frackville 

Mission 

Each CBOC has an appointed Women’s Health Liaison. 

18 VHA Handbook 1330.01.
 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.
 

VA OIG Office of Healthcare Inspections 10 
McKean, Venango, Camp Hill, Pottsville/Frackville, Mission, Newcastle, Hibbing, and Rochester 

Areas Reviewed (continued)
 

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 

Noncompliant 

Pottsville/
 

Frackville
 

Mission
 

VISN 4, Lebanon VAMC – Camp Hill and Pottsville/Frackville 

Appointment of Women’s Health Liaison. We did not find evidence of a Women’s 

Health Liaison at the Pottsville/Frackville CBOC; therefore, no collaboration occurred 

with the parent facility’s Women Veterans Program Manager on women’s health issues. 

Notice of Results. Four of 12 patients did not have documented notice of normal 

mammogram results within 30 days at the Camp Hill and Pottsville/Frackville CBOCs. 

One of three patients did not have documented notice of an abnormal mammogram 

result within 14 days at the Pottsville/Frackville CBOC. 

Mammography Orders and Access. Providers did not enter mammogram radiology 

orders for fee basis mammograms in CPRS for the 12 patients reviewed at the Camp 

Hill and Pottsville/Frackville CBOCs. We also found that not all breast imaging results 

were linked to the appropriate radiology mammogram or breast study order. All breast 

imaging and mammography results must be linked to the appropriate radiology 

mammogram or breast study order. 

VISN 23, VA Black Hills HCS – Mission and Newcastle 

Patient Notification. We did not find documented evidence of patient notification of 

mammography results within 30 days for the two patients reviewed at the Newcastle 

CBOC. 

Appointment of Women’s Health Liaison. We did not find evidence of a Women’s 

Health Liaison at the Mission CBOC; therefore, no collaboration occurred with the 

parent facility’s Women Veterans Program Manager on women’s health issues. 

VISN 23, Minneapolis VA HCS – Hibbing and Rochester 

Monitoring of Mammography Services. The Hibbing and Rochester CBOCs had not 

established an effective process for monitoring mammography services as required by 

VHA. VHA facilities are required to establish and document a process for tracking 

results from mammography procedures performed off site and ensuring that required 

data is captured and entered into CPRS.22 Additionally, facilities must ensure timely 

tracking and follow up of all abnormal mammography results.23 

Mammography Orders and Access. At the Hibbing and Rochester CBOCs, providers 

did not enter CPRS mammogram radiology orders for fee base mammograms 

22 VHA Handbook 1330.01. 23 VHA Handbook 1330.01. 

VA OIG Office of Healthcare Inspections 11 
McKean, Venango, Camp Hill, Pottsville/Frackville, Mission, Newcastle, Hibbing, and Rochester 

performed after June 1, 2010. All breast imaging and mammography results must be 

linked to the appropriate radiology mammogram or breast study order. 

Mammography Results. At the Hibbing and Rochester CBOCs, mammography results 

were not consistently (six of seven) documented using the BI-RADS categories for 

mammograms performed after June 1, 2010. 

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.24 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. 

Hibbing 

Rochester 

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. 

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. 

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

specific.25 

The determination to continue current privileges are based in part 

on results of OPPE activities. 

Mission The OPPE and reappraisal process included consideration of such 

factors as clinical pertinence reviews and/or performance measure 

compliance. 

24 VHA Handbook 1100.19. 25 VHA Handbook 1100.19. 

VA OIG Office of Healthcare Inspections 12 
McKean, Venango, Camp Hill, Pottsville/Frackville, Mission, Newcastle, Hibbing, and Rochester 

Noncompliant Areas Reviewed (continued) 

Camp Hill 

Mission 

Newcastle 

Relevant provider-specific data was compared to aggregated data 

of other providers holding the same or comparable privileges. 

Hibbing 

Newcastle 

Rochester 

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 4, Lebanon VAMC – Camp Hill 

Performance Improvement Data. Two MH providers did not have evidence that the 

facility compared practitioner data either to those practitioners doing similar procedures 

or to aggregated data of those privileged practitioners with the same or comparable 

privileges at the Camp Hill CBOC. 

VISN 23, VA Black Hills HCS – Mission and Newcastle 

OPPE. We found that OPPEs did not include consideration of such factors as clinically 

pertinent reviews or performance measure compliance. Criteria for an OPPE were not 

clearly defined by local policy or under guidance of a parent facility policy at either the 

Mission or Newcastle CBOC. 

Performance Improvement Data. We found that relevant provider-specific data was not 

compared to aggregated data of those privileged providers who hold the same or 

comparable privileges at the Mission and Newcastle CBOCs. 

Scopes of Practice. We reviewed the files of two providers from the Newcastle CBOC 

and found that the scopes of practice were provider-specific but were not facility or 

service-specific. The scopes of practice did not include the names of the facilities the 

providers were assigned to or the providers’ specialty practices. 

VISN 23, VA Minneapolis HCS – Hibbing and Rochester 

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

privileges for procedures that cannot be supported at Hibbing CBOC. One provider 

from the Hibbing CBOC was granted privileges to perform thoracentesis. 

FPPE. We reviewed the files of two newly hired physicians. While there were FPPEs 

implemented for both providers, they did not contain defined and measurable criteria by 

which to evaluate performance.26 

26 VHA Handbook 1100.19. 

VA OIG Office of Healthcare Inspections 13 
McKean, Venango, Camp Hill, Pottsville/Frackville, Mission, Newcastle, Hibbing, and Rochester 

Scope of Practice. We reviewed the files of four providers and found that two did not 

have scopes of practice. 

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 

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. 

Mission 

Newcastle 

The facility has identified skill competencies for the CBOC. 

Mission 

Newcastle 

Staff competency was initially assessed and documented as a part 

of the CBOC orientation. 

Camp Hill 

Pottsville/ 

Frackville 

Mission 

Newcastle 

Rochester 

Patient care staff identified skill competencies were validated and 

documented. 

Table 9. Skills Competency 

VISN 4, Lebanon VAMC – Camp Hill and Pottsville/Frackville 

Skill Competency. The Camp Hill and Pottsville/Frackville CBOCs’ competencies were 

not consistently validated and documented for six of the seven patient care staff 

members reviewed. Three staff members lacked evidence of annual competency in 

blood glucose testing and one of three did not have an EKG competency at the 

Pottsville/Frackville CBOC. Three of four staff members did not have evidence of 

annual competencies for blood glucose testing, phlebotomy, assistive devices, EKG, 

and ear irrigation at the Camp Hill CBOC. Local policy requires that competencies are 

evaluated annually. 

VISN 23, VA Black Hills HCS – Mission and Newcastle 

Skill Competency. We did not find documentation of current competency for blood 

glucose testing for one staff member at the Newcastle CBOC. A staff member did not 

have current competency for assistive care devices at the Mission CBOC. Local policy 

requires annual competency evaluation. 

VA OIG Office of Healthcare Inspections 14 
McKean, Venango, Camp Hill, Pottsville/Frackville, Mission, Newcastle, Hibbing, and Rochester 

Orientation. Staff skills’ competencies were not identified, initially assessed, and 

documented as part of orientation or evaluated annually per local policy at the Mission 

and Newcastle CBOCs. 

VISN 23, VA Minneapolis HCS –Rochester 

Skill Competency. We found that two patient care staff members did not have current 

phlebotomy competency assessments at the Rochester CBOC. This skill was identified 

by the facility as a core competency for these staff members. In addition, the facility’s 

local policy requires annual competency evaluation. 

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. 

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.). 

Pottsville/ 

Frackville 

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

McKean County The patient care area is safe. 

Medical equipment is checked routinely (biomedicine tags when 

applicable). 

Pottsville 

Mission 

Newcastle 

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

areas as identified by the vulnerability risk assessment. 

Camp Hill 

Pottsville/ 

Frackville 

Privacy is maintained. 

Pottsville/ 

Frackville 

IT security rules are adhered to. 

Camp Hill 

Pottsville/ 

Frackville 

Patients’ PII is secured and protected. 

There is alcohol hand wash or a soap dispenser and sink 

available in each examination room. 

The sharps containers are less than 3⁄4 full. 

VA OIG Office of Healthcare Inspections 15 
McKean, Venango, Camp Hill, Pottsville/Frackville, Mission, Newcastle, Hibbing, and Rochester 

Noncompliant Areas Reviewed (continued) 

Mission 

Newcastle 

Rochester 

There is evidence of fire drills occurring at least annually. 

Fire extinguishers are easily identifiable. 

Mission 

Newcastle 

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

Mission Staff use two patient identifiers for blood drawing procedures. 

The CBOC is included in facility-wide EOC activities. 

Table 10. EOC 

VISN 4, Erie VAMC – McKean County 

Signage. We found that the escape pathway to the designated means of egress 

included a paper product “EXIT” sign at the McKean County CBOC. The sign did not 

illuminate; therefore, in the event of an emergency, the exit pathway could not be easily 

identified. 

Clinic Entrance Doorbell. We found that the clinic doorbell did not ring at the McKean 

County CBOC. The intent of the doorbell is to alert staff that a veteran is in need of 

assistance to access the clinic. The staff told us that the doorbell has never been 

functional. 

VISN 4, Lebanon VAMC – Camp Hill and Pottsville/Frackville 

Clean and Dirty Storage. We found clean patient care supplies and dirty equipment 

stored in an unlocked room at the Pottsville/Frackville CBOC (Pottsville campus). 

In an examination room, we found two unlabeled fluid-filled syringes stored in a file 

cabinet drawer. In other drawers, we found expired syringes. We also found shoes 

placed on top of sterile supplies. 

In the laboratory, in an unlocked cabinet, we found two large containers filled with used 

syringes, contaminated needles, and specimen tubes containing blood. The containers 

were not labeled as biohazard waste. 

The JC requires proper storage of equipment and supplies to minimize infection.27 

Additionally, VA policy requires physical separation of soiled from clean areas to include 

patient care supplies and equipment.28 The Occupational Safety and Health 

27 The JC Hospital Accreditation Program Manual 2009 Addition, Standard IC 02.02.01.
 28 VHA Handbook 7176, Supply, Processing, and Distribution (SPD) Operational Requirements, Washington, DC,
 

August 16, 2002.
 

VA OIG Office of Healthcare Inspections 16 
McKean, Venango, Camp Hill, Pottsville/Frackville, Mission, Newcastle, Hibbing, and Rochester 

Administration Bloodborne Pathogen Standard, 29 CFR 1910.1030(g)(1)(i), requires 

warning labels to be placed on all regulated waste.29 

IT Security. At the Pottsville campus, the IT equipment and the building’s alarm system 

were inside a cage located in a locked room with maintenance supplies and tools. 

Security personnel maintained the keys to the room and IT cage; however, we were 

informed that the building’s maintenance staff also had keys to the IT cage. During our 

inspection, we found the IT cage door open. 

At the Frackville campus, IT equipment was located inside a locked room with signage 

indicating biohazard waste. Inside the room were boxes of medical and offices supplies 

stacked on pallets and on a freezer. Reportedly, the freezer was utilized for storing 

biohazard waste. We were informed that multiple staff members had access to this 

room. 

Access logs had no entries since 2009 and 2010, respectively, at the Pottsville and 

Frackville campuses. 

VA policy requires that access to areas that contain equipment or information critical to 

IT infrastructure be limited to authorized personnel.30 All entrances to sensitive areas 

will have a sign-in/out log for tracking individuals entering these areas. Entrance doors 

to these areas shall remain locked, unless necessary to open for deliveries or 

maintenance of equipment. 

Patient and Environmental Safety. MH services are offered 2 days per week at the 

Pottsville/Frackville CBOC (Pottsville campus). We found that this clinic did not have a 

panic alarm system. We also found two examination rooms and two unlocked offices 

had corded blinds and windows that could be opened wide enough to potentially 

present a risk to patient safety. The clinic was on the second floor of a multi-purpose 

building. The facility had not conducted a Hazard Vulnerability Assessment. The 

assessment addresses the steps (if any) the clinic should have in place based on the 

clinic’s location and patient population. 

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

Camp Hill and Pottsville/Frackville CBOCs. 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. 

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

process at the Camp Hill and Pottsville/Frackville CBOCs. VHA policy requires auditory 

29 Regulated waste is potentially infectious material; contaminated items that release blood or other potentially
 

infectious materials, items that are caked with dried blood or other potential infectious materials; contaminated
 

sharps; and other waste containing blood or other potentially infectious materials.

30 VA Handbook 6500.
 

VA OIG Office of Healthcare Inspections 17 
McKean, Venango, Camp Hill, Pottsville/Frackville, Mission, Newcastle, Hibbing, and Rochester 

privacy when staff discuss sensitive patient issues.31 Patients communicate with staff in 

open stations 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 a zone of audible privacy during the check-in process. 

Patient Privacy. Three examination rooms did not have privacy curtains, and two of 

three examination tables were placed with the foot facing the door at the 

Pottsville/Frackville CBOC (Pottsville campus). VHA policy details specific 

requirements to ensure patient privacy for all veterans, particularly women veterans.32 

VISN 23, VA Black Hills HCS – Mission and Newcastle 

Fire Drills. We did not find evidence of an annual fire drill for 2009 or 2010 at the 

Mission and Newcastle CBOCs. 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.33 

Hand Hygiene. Hand hygiene monitors or data collection had not been initiated prior to 

our on-site visit at the Mission and Newcastle CBOCs. A comprehensive infection 

control program is intended to foster a culture of hand hygiene compliance that ensures 

the control of infectious diseases. 

Panic Alarms. We did not find panic alarms for the administrative or clinical staff at the 

Mission and Newcastle CBOCs. The facility had not conducted a vulnerability risk 

assessment to determine whether panic alarms were appropriate at the Mission and 

Newcastle CBOCs. 

Patient Identification. The Mission 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. 

VISN 23, VA Minneapolis HCS – Rochester 

Fire Drills. We did not find evidence of an annual fire drill for 2010 at the Rochester 

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.34 

31 VHA Handbook 1605.14
 32 VHA Handbook 1330.01.
 33 Joint commission Standards EC 02.03.01.
 34 The JC Standard EC 02.03.01.
 

VA OIG Office of Healthcare Inspections 18 
McKean, Venango, Camp Hill, Pottsville/Frackville, Mission, Newcastle, Hibbing, and Rochester 

Emergency Management 

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

defining how medical emergencies, including MH, are handled.35 Table 11 shows the 

areas reviewed for this topic. 

Noncompliant Areas Reviewed 

Mission 

Newcastle 

There is a local medical emergency management plan for this 

CBOC. 

The staff can articulate the procedural steps of the medical 

emergency plan. 

The CBOC clinical staff are trained in cardiopulmonary resuscitation 

with the use of an AED. 

Pottsville The CBOC has an AED onsite for cardiac emergencies. 

Mission 

Newcastle 

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

The staff can articulate the procedural steps of the MH emergency 

plan. 

Table 11. Emergency Management 

VISN 4, Lebanon VAMC – Pottsville/Frackville 

AED. An AED was not available; therefore, the absence of an AED may lead to an 

undesirable clinical outcome in the event of an emergency at the Pottsville campus. 

VISN 23, VA Black Hills HCS – Mission and Newcastle 

Local Emergency Management SOP. VHA policy requires each CBOC to have a local 

policy or SOP defining how medical emergencies, including MH, are handled. Neither 

CBOC had a local policy or SOP to instruct staff on how they should respond if a patient 

presented with a cardiac arrest, hypoglycemic event, and/or MH issues. 

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.36 

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

needed improvement. Details regarding the finding follow the table. 

35 VHA Handbook 1006.1.
 36 VHA Handbook 1101.02, Primary Care Management Module, April 21, 2009.
 

VA OIG Office of Healthcare Inspections 19 
McKean, Venango, Camp Hill, Pottsville/Frackville, Mission, Newcastle, Hibbing, and Rochester 

Noncompliant Areas Reviewed 

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

being seen for their first appointment. 

Mission 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 23, VA Black Hills HCS – Mission 

The Black Hills HCS had approximately 17,400 active patients, with approximately 

180 being assigned to the Mission CBOC. There were approximately 10 patients 

assigned to a Mission PCP in PCMM that were also assigned to an additional PCP at 

other facilities and were not approved. Of the 10 patients, 2 had not had a visit at this 

clinic since December 2008. Patients with two or more PCPs assigned inflate primary 

care panel sizes and increase medical care costs for contracted care. 

VISN 23, Minneapolis VA HCS – Hibbing 

Enrollment procedures in PCMM at the Hibbing CBOC are not performed in accordance 

with the VHA policy. Enrollment should be performed when the patient has completed 

his appointment, not when the patient has a scheduled appointment. 

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. 

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: 

a. Requirements for payment. 

b. Rate and frequency of payment. 

c. Invoice format. 

d. Performance measures (including incentives/penalties). 

VA OIG Office of Healthcare Inspections 20 
 

 

McKean, Venango, Camp Hill, Pottsville/Frackville, Mission, Newcastle, Hibbing, and Rochester 

Noncompliant Areas Reviewed (continued) 

Pottsville/ 

Frackville 

McKean 

County 

e. Billing the patient or any other third party. 

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

Pottsville/ 

Frackville 

Hibbing 

(3) Invoice validation process. 

(4) The COTR designation and training. 

Mission (5) Contractor oversight provided by the COTR. 

(6) Timely access to care. 

Table 13. Review of PC and MH Contract Compliance 

VISN 4, Erie VAMC ─ McKean County 

Billing the Patient or Other Third Party. The McKean County contract does not include 

a provision that states payment from the VA constitutes payment in full and prohibits the 

contractor from seeking reimbursement from any other source. Inclusion of this 

provision would clearly state that it would be considered fraudulent for the contractor to 

bill the patient or other third party insurance sources (including Medicare) for services 

rendered to veteran enrollees under this contract. 

VISN 4, Lebanon VAMC ─ Pottsville/Frackville 

Billing the Patient or Other Third Party. The Pottsville/Frackville contract does not 

include a provision that states payment from the VA constitutes payment in full and 

prohibits the contractor from seeking reimbursement from any other source. We found 

that a contracted primary care provider at the Frackville campus was also seeing VA 

patients in a private practice. This relationship has the potential for self-referral and 

additional payment for services that are covered under the VA contract. Inclusion of this 

provision would clearly state that it would be considered fraudulent for the contractor to 

bill the patient or other third party insurance sources (including Medicare) for services 

rendered to veteran enrollees under this contract. 

Invoice Validation Process. The COTR receives paper copies of the monthly invoices 

and supporting documentation. The validation process is very labor and time intensive. 

The process would be improved if the contractor provided the COTR with invoice and 

support in a spreadsheet format so the data could be analyzed and validated 

electronically. The COTR has initiated changes so that monthly data will be submitted 

electronically by the contractor. 

The facility was not monitoring contract requirements to determine the contractor’s 

eligibility for payment. The contract contains specific requirements for the contractor to 

receive payment to include: 1) annual vesting visit, 2) authenticated progress note in 

VistA, and 3) updated means test. 

VA OIG Office of Healthcare Inspections 21 
 

 

McKean, Venango, Camp Hill, Pottsville/Frackville, Mission, Newcastle, Hibbing, and Rochester 

VISN 23, Black Hills HCS ─ Mission 

Oversight. The contract has reporting requirements for specific reports due monthly, 

quarterly, and annually, which are intended to provide the facility management with an 

assessment of the CBOC’s performance. We did not find any performance issues; 

however, these reports have not been provided to the facility as required by the 

contract. 

VISN 23, Minneapolis VAMC ─ Hibbing 

Invoice Validation Process. The facility needs to strengthen the invoice validation 

process to more accurately assess the total of billable enrollees reported on the 

contractor’s invoice prior to certification for payment. Under the current process, the 

COTR compares the number of invoiced enrollees to a report from the PCMM, which 

approximates the number of billable enrollees on the invoice. Although we did not find 

any instances of overbilling, the current invoice validation process relies upon the 

internal controls of the contractor to ensure that the invoice payments are correct. The 

inherent risk of overpayments occurs if there are breakdowns in the contractor’s internal 

controls and the VA does not have processes to detect potential overpayments. 

Technical Review. The signed contract dated April 9, 2009, did not include numerous 

contract provisions required by VHA policy and directives, such as the statement of 

work, performance measures, and commercial contract provisions.37 The contract 

consisted of the contractor’s proposal and contract amendments but did not include or 

refer to a significant portion of the original request for proposal. Additionally, we were 

provided a draft of a more complete contract that the contractor possessed; however, 

this contract was not signed by either party. 

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

VA OIG Office of Healthcare Inspections 22 
McKean, Venango, Camp Hill, Pottsville/Frackville, Mission, Newcastle, Hibbing, and Rochester 

Appendix A 

VISN 4 Director Comments 

Department of 

Veterans Affairs	 Memorandum 

Date:	 July 8, 2011 

From:	 Director, VISN 4 (10N4) 

Subject:	 CBOC Reviews: McKean County and Venango County, 

PA; and Camp Hill and Pottsville/Frackville, PA 

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

Director, Management Review Service (VHA 10A4A4) 

1.	 I have reviewed the responses provided by the Erie and Lebanon VA 

Medical Centers and I am submitting it to your office as requested. I 

concur with all responses. 

2.	 If you have any questions or require additional information, please 

contact Barbara Forsha, VISN 4 Quality Management Officer at 412­

822-3290. 

(original signed by:) 

MICHAEL E. MORELAND, FACHE 

VA OIG Office of Healthcare Inspections 23 
McKean, Venango, Camp Hill, Pottsville/Frackville, Mission, Newcastle, Hibbing, and Rochester 

Appendix B 

Erie VAMC Director Comments 

Department of 

Veterans Affairs	 Memorandum 

Date:	 July 12, 2011 

From:	 Director, Erie VAMC (562/00) 

Subject:	 CBOC Review: McKean County and Venango County, 

PA 

To:	 Director, VISN 4 (10N4) 

I have reviewed the draft report of the Inspector General Community 

Based Outpatient Clinic Review of the Bradford (McKean County) and 

Franklin (Venango County), PA. I concur with the findings outlined in this 

report and have included corrective action plans for each 

recommendation. 

(original signed by:) 

MICHAEL D. ADELMAN, MD 

VA OIG Office of Healthcare Inspections 24 
McKean, Venango, Camp Hill, Pottsville/Frackville, Mission, Newcastle, Hibbing, and Rochester 

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 Short-Term Fee Basis consults for the 

McKean County CBOC are approved by appropriate leadership or a designee in 

accordance with VHA and local policy. 

Concur 

Target date for completion: 8/31/2011 

A Fee Basis Medical Center Memorandum (MCM) will be developed to include 

guidance on which Fee authorizations must be approved by the Chief Of Staff or 

designee and which Fee Basis authorizations shall have automatic approval in 

accordance with national and local policy. The Short Term Fee Basis draft MCM will be 

sent for concurrence to Clinical Services and leadership. 

Recommendation 2. 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 McKean County CBOC. 

Concur 

Target date for completion: 8/31/2011 

Fee Basis Staff were trained on 6/27/2011regarding the documentation requirements for 

all Fee consults/authorizations that are sent in full to the patient. A Short Term Fee 

Basis MCM will be developed to include the documentation requirements in the 

responsibility section of the MCM. The Short Term Fee Basis draft MCM will be sent for 

concurrence to Clinical Services and leadership. 

Recommendation 3. We recommended that the ordering practitioners, or surrogate 

practitioners, document in the medical record that they reviewed the Short-Term Fee 

Basis report at the McKean County CBOC. 

Concur 

Target date for completion: 8/31/2011 

The COTR will educate the McKean CO CBOC providers and staff regarding the 

requirement to document in the patient’s medical record that the short-term, fee-basis 

results were reviewed by the ordering provider. The COTR will audit the appropriate 

patient medical records to verify compliance with the required documentation. 

VA OIG Office of Healthcare Inspections 25 
McKean, Venango, Camp Hill, Pottsville/Frackville, Mission, Newcastle, Hibbing, and Rochester 

Recommendation 4. 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 McKean County 

CBOC. 

Concur 

Target date for completion: 8/31/2011 

The COTR will educate the McKean CBOC practitioners and staff that the results of 

short-term, fee-basis consults must be communicated to the patient within 14 days from 

the date made available to the ordering practitioner and that action must be 

documented in the medical record. The COTR will audit the appropriate patient medical 

records to verify compliance with the required documentation. 

Recommendation 5. We recommended that exit signage illuminates to ensure that 

patients, visitors, and staff can exit safely during an emergency at the McKean County 

CBOC. 

Concur 

Target date for completion: 7/1/2011 - Completed 

The Contracting Officer notified the contractor of the McKean CBOC regarding the OIG 

recommendation to install an illuminated exit signage on 6/29/2011. The illuminated 

emergency exit signage was installed on 7/1/2011 by Pure Tech of Bradford, PA and is 

fully functional. The COTR validated completion of the installation on 7/1/2011. 

Recommendation 6. We recommended that the doorbell is repaired at the McKean 

County CBOC. 

Concur 

Target date for completion: 7/31/ 2011 

The Contracting Officer notified the contractor of the McKean CBOC regarding the OIG 

recommendations on 6/29/2011. A wireless communicator with intercom will be installed 

by Pure Tech of Bradford, PA. A site test will be performed following installation. 

Confirmation of successful installation will be validated by the COTR. 

Recommendation 7. We recommended that the Contracting Officer prepare a contract 

modification to add a provision that prohibits the contractor from billing the patient or 

any other source for services that are covered under the VA primary care contract. 

Concur 

Target date for completion: 7/31/2011 

VA OIG Office of Healthcare Inspections 26 
McKean, Venango, Camp Hill, Pottsville/Frackville, Mission, Newcastle, Hibbing, and Rochester 

The Contracting Officer will prepare a contract modification to add a provision to the 

contract that prohibits the contractor from billing the patient or any other source for 

services that are covered under the VA primary contract. 

VA OIG Office of Healthcare Inspections 27 
McKean, Venango, Camp Hill, Pottsville/Frackville, Mission, Newcastle, Hibbing, and Rochester 

Appendix C 

Lebanon VAMC Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: July 7, 2011 

From: Director, Lebanon VAMC (595/00) 

Subject: CBOC Review: Camp Hill and Pottsville/Frackville 

To: Director, VISN 4 (10N4) 

On behalf of the Lebanon VA Medical Center, I want to express my 

appreciation to the Office of Inspector General (OIG) Office of Healthcare 

Inspections for the comprehensive Community Based Outpatient Clinic 

Reviews in Camp Hill and Pottsville/Frackville, Pennsylvania, conducted 

May 17 – 19, 2011. 

The attached provides comment to the reported findings and outlines the 

actions taken by the staff of the Lebanon VA Medical Center in response 

to the OIG recommendations. 

(original signed by:) 

Robert W. Callahan, Jr. 

Director 

VA OIG Office of Healthcare Inspections 28 
McKean, Venango, Camp Hill, Pottsville/Frackville, Mission, Newcastle, Hibbing, and Rochester 

Comments to Office of Inspector General’s Report
 

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

to the Office of Inspector General’s report: 

OIG Recommendations 

Recommendation 8. We recommended that the facility develop a local policy for 

Short-Term Fee Basis consults. 

Concur 

Target date for completion: September 1, 2011 

Facility Response: A process to address short-term fee basis was initiated prior to the 

OIG review. Formalization of the practice is being finalized by the Care Coordination 

Office in collaboration with Primary Care Leadership. 

Recommendation 9. 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 Camp Hill CBOC. 

Concur 

Target date for completion: September 1, 2011 

Facility Response: A process to address short-term fee basis was initiated prior to the 

OIG review. Formalization of the practice is being finalized by the Care Coordination 

Office in collaboration with Primary Care Leadership. 

Recommendation 10. We recommended that the ordering practitioners, or surrogate 

practitioners, document in the medical record that they reviewed the Short-Term Fee 

Basis report at the Camp Hill CBOC. 

Concur 

Target date for completion: August 5, 2011 

Facility Response: ACOS Primary Care is briefing all providers that they must make 

comment illustrating their review of the Short-Term Fee Basis consult result. Review of 

all test results, including short-term fee results, will be added to the Test Results 

Notification Reminder. This will provide easier compliance for practitioner. 

Recommendation 11. 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 Camp Hill 

CBOC. 

VA OIG Office of Healthcare Inspections 29 
McKean, Venango, Camp Hill, Pottsville/Frackville, Mission, Newcastle, Hibbing, and Rochester 

Concur 

Target date for completion: August 5, 2011 

Facility Response: The reminder template will be revised for ordering practitioners to not 

only state that they reviewed the results, but also that notification to the patient was 

performed within 14 days. 

Recommendation 12. We recommended that the parent Facility Director appoints a 

Women’s Health Liaison who collaborates with the parent facility’s Women Veterans 

Program Manager on women’s health issues for the Camp Hill and Pottsville/Frackville 

CBOCs. 

Concur 

Target date for completion: September 5, 2011 

Facility Response: Currently, personnel are assigned but there is no official letter of 

appointment. The exception is Pottsville/Frackville which does not have a Women's 

Health Liaison on-site. Official letters of appointment will be developed to appoint 

Women's Health Liaison for all CBOCs. 

Recommendation 13. We recommended that the facility establish a process to 

document patient notification results in the medical record at the Camp Hill and 

Pottsville/Frackville CBOCs. 

Concur 

Target date for completion: August 5, 2011 

Facility Response: The reminder template will be revised for ordering practitioners to not 

only state that they reviewed the results, but also that notification to the patient was 

performed within 14 days. 

Recommendation 14. We recommended that the ordering providers at the Camp Hill 

and Pottsville/Frackville CBOCs enter all radiology orders for fee basis mammograms in 

CPRS and link breast imaging results to the radiology mammogram order. 

Concur 

Target date for completion: August 5, 2011 

Facility Response: Radiology staff responsible for scanning of documents will be trained 

to link results to the Mammogram order/consult. 

VA OIG Office of Healthcare Inspections 30 
McKean, Venango, Camp Hill, Pottsville/Frackville, Mission, Newcastle, Hibbing, and Rochester 

Recommendation 15. We recommended that the facility compares practitioner data 

either to those practitioners doing similar procedures or to aggregated data of those 

privileged practitioners with the same or comparable privileges at the Camp Hill CBOC. 

Concur 

Target date for completion: August 5, 2011 

Facility Response: ACOS BH will develop system to compare like practitioners. 

Recommendation 16. We recommended that skill competencies are validated and 

documented for all patient care staff at the Camp Hill and Pottsville/Frackville CBOCs. 

Concur 

Target date for completion: Completed – June 29, 2011 

Facility Response: Patient care staff competencies identified by the OIG Inspection 

Team and all other patient care staff competencies for Frackville/Pottsville and Camp 

Hill CBOCs were reviewed by the respective clinic nurse managers. Competencies 

were updated to be consistent with organizational policy expectations and the skills 

expected of staff in these clinical areas. 

Recommendation 17. We recommended that the Director ensures that clean and dirty 

items at the Pottsville/Frackville CBOC (Pottsville campus) are stored according to VHA 

policy. 

Concur 

Target date for completion: Completed – May 18, 2011 

Facility Response: Lebanon VAMC Infection Control staff deployed to the clinic. Storing 

of supplies with office supplies and other supplies (CPR mannequins) considered "dirty" 

was corrected. Employed and contracted staff were briefed on proper storage of 

supplies. Schuylkill Medical Center COTR was again briefed on July 6, 2011 about 

these concerns. 

Monitoring of the environment will continue during Lebanon’s ongoing Environment of 

Care Rounds. 

Recommendation 18. We recommended that the Chief of OI&T evaluates the use of 

the IT closet and implements appropriate measures according to VA policy at the 

Pottsville/Frackville CBOCs. 

Concur 

Target date for completion: Completed - June 10, 2011 

VA OIG Office of Healthcare Inspections 31 
McKean, Venango, Camp Hill, Pottsville/Frackville, Mission, Newcastle, Hibbing, and Rochester 

Facility Response: IT spaces at Frackville and Pottsville have been evaluated and 

addressed as follows: 

The switches at both of these locations have port security enabled to provide security 

for the VA network/data. Port security is set so that each port will allow only 1 device 

(MAC address to connect). If a device is unplugged and another device is plugged in to 

the same port the port will automatically shut-down and prohibit any further access until 

evaluated and resolved by Lebanon OI&T staff. Ports which do not have a device 

connected are shut-down so that no access is possible. 

Frackville – as of June 10, 2011 this switch has been relocated and protected with a 

locked enclosure. Keys to this enclosure are in the possession of Lebanon IT staff. 

There is insufficient room at the Pottsville location for this type of enclosure. 

We do provide a list of Lebanon OI&T Staff who are allowed access to these locations 

and a sign-in roster for any visitors which we would need to escort into these locations 

to perform service work on our equipment as outlined in VA Handbook 6500. Neither 

roster has recent signatures since this would be a very rare occasion as 

repairs/replacements are typically completed by Lebanon OI&T staff. We do not have 

keys to these areas and require escort into these areas by IT/security staff at these 

locations. 

Recommendation 19. We recommended that a Hazard Vulnerability Assessment be 

conducted to determine if potential patient or environmental safety hazards exist at the 

Pottsville/Frackville (Pottsville campus) CBOC. 

Concur 

Target date for completion: Completed – May 23, 2011 

Facility Response: The Medical Center Emergency Management Coordinator received 

Hazard Vulnerability Assessments for the Pottsville/Frackville clinics and found them to 

be acceptable. 

The staff of the contracted clinic are expected to follow the emergency response as 

guided under the auspices of their parent facility. Future revisions to the current contract 

will include the parent company providing the Lebanon VA Medical Center with their 

annual Hazard Vulnerability Assessments for the involved clinics. 

Recommendation 20. We recommended that the transportation of laboratory 

specimens is secured at the Camp Hill and Pottsville/Frackville CBOCs. 

Concur 

Target date for completion: August 1, 2011 

VA OIG Office of Healthcare Inspections 32 
McKean, Venango, Camp Hill, Pottsville/Frackville, Mission, Newcastle, Hibbing, and Rochester 

Facility Response: To ensure the security of all lab specimens transported from the 

CBOC to the Lebanon VA Medical Center we have instituted the use of Breakaway 

Lock Seals. When the last lab specimen is placed into the box a Breakaway Lock Seal 

will be placed on the transportation box by the nurse or Health Technician assigned to 

the lab. The Medical Center laboratory staff will check the seal on arrival to ensure the 

integrity of the seal is intact. The placing of the seal on the boxes has already been 

initiated. The SOP is currently being updated. All staff will be trained to the changes in 

the SOP via staff meetings. 

Recommendation 21. We recommended that auditory privacy be maintained during 

the check-in process at the Camp Hill and Pottsville/Frackville CBOCs. 

Concur 

Target date for completion: August 5, 2011 

Facility Response: The Privacy Officer, utilizing the July 8, 2011 memorandum titled 

“Auditory Privacy During CBOC Check-in Process” from the Deputy Under Secretary for 

health for Operations and Management, will visit the Camp Hill, Pottsville, and Frackville 

clinics to provide hands on training and education to staff on the importance of privacy 

issues and securing confidential information. 

Recommendation 22. We recommended that the facility ensures the appropriate 

measures are in place to ensure patient privacy is maintained at the Pottsville/Frackville 

CBOC (Pottsville campus). 

Concur 

Target date for completion: August 5, 2011 

Facility Response: Privacy curtains will be hung and placed in three of the examination 

rooms at the Pottsville clinic. Two exam tables will be relocated in the room to comply 

with VA Handbook 1330.01 requirements to ensure patient privacy for all veterans, 

particularly women veterans. 

Recommendation 23. We recommended that managers ensure that an AED is 

available at the Pottsville/Frackville CBOC (Pottsville campus). 

Concur 

Target date for completion: September 15, 2011 

Facility Response: An AED should be readily accessible in the clinic proper so as not to 

have a delay in emergent care. Lebanon VAMC will purchase and place one in the 

clinic. 

Recommendation 25. We recommended that the Contracting Officer prepares a 

contract modification to add a provision that prohibits the contractor from billing the 

VA OIG Office of Healthcare Inspections 33 
McKean, Venango, Camp Hill, Pottsville/Frackville, Mission, Newcastle, Hibbing, and Rochester 

patient or any other source for services that are covered under the VA primary care 

contract. 

Concur 

Target date for completion: September 1, 2011 

Facility Response: The current contract is under review for deletions and modifications 

to be more specific in regards to prohibition of double billing for services provided. This 

item is covered on page 18 item G of the current contract but requires clarification. 

Contract will be amended to be more specific and disallow double billing. 

Recommendation 26. We recommended that the Facility Director and Contracting 

Officer ensure that contracted primary care providers are aware of ethics rules 

regarding self-referral and are free of any conflicts of interest. 

Concur 

Target date for completion: September 1, 2011 

Facility Response: The current contract is under review for deletions and modifications 

to be more specific in regards to ethical behavior of self-referral. The contract will be 

amended to include more specific language disallowing self-referral of patients. 

Secondly, MCM 00-24 Code of Ethical Behavior was given to Schuylkill Medical 

Center's Contracting Officer Technical Representative for briefing of self-referral 

mechanisms to contractor employees. 

Recommendation 27. We recommended that the Facility Director and Contracting 

Officer ensure that contract provisions are written and enforced to ensure proper 

payment specifically as they relate to patient disenrollment, vesting visits, VistA notes, 

and means tests. 

Concur 

Target date for completion: Completed - June 13, 2011 

Facility Response: Currently Lebanon's COTR has developed a VistA Ad Hoc Report to 

ensure compliance with exam coding requirements as exhibited in the contract. This Ad 

Hoc report is then compared with invoice to ensure proper line item billing. 

VA OIG Office of Healthcare Inspections 34 
McKean, Venango, Camp Hill, Pottsville/Frackville, Mission, Newcastle, Hibbing, and Rochester 

Appendix D 

VISN 23 Director Comments 

Department of 

Veterans Affairs	 Memorandum 

Date:	 July 11, 2011 

From:	 Director, VISN 23 (10N23) 

Subject:	 CBOC Reviews: Mission, SD and Newcastle, WY; and 

Hibbing and Rochester, MN 

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

Director, Management Review Service (VHA 10A4A4) 

Thank you for the opportunity to provide a report on the draft findings from 

the CBOC reviews of the Mission, SD; Newcastle, WY; Hibbing and 

Rochester, MN. I have reviewed the report from the site visits that 

occurred during the week of May 14, 2011. I concur with the 

recommendations. 

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

recommendations in the draft report, please contact me at 612-725-1968. 

(original signed by:) 

JANET P. MURPHY, MBA 

Network Director 

VA OIG Office of Healthcare Inspections 35 
McKean, Venango, Camp Hill, Pottsville/Frackville, Mission, Newcastle, Hibbing, and Rochester 

Appendix E 

VA Black Hills HCS Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: July 8, 2011 

From: Director, VA Black Hills HCS (568/00) 

Subject: CBOC Reviews: Mission, SD and Newcastle, WY 

To: Director, VISN 23 (10N23) 

Attached please find our response to the VA Black Hills Health Care 

System CBOC Review: Mission, SD and Newcastle, WY conducted May 

16-18, 2011. 

If you have any questions, you may contact the Director at VA Black Hills 

Health Care System at (605) 347-2511 Extension 7170. 

(original signed by:) 

Stephen R. DiStasio, FACHE 

Acting Director 

VA OIG Office of Healthcare Inspections 36 
McKean, Venango, Camp Hill, Pottsville/Frackville, Mission, Newcastle, Hibbing, and Rochester 

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 a plan for the Mission and Newcastle 

CBOCs be developed that defines how MH emergencies that require a higher level of 

care are addressed. 

Concur 

Target date for completion: September 30, 2011 

The following will be incorporated into the Standard Operating Procedure (SOP) for all 

CBOC response to MH Emergencies: 

Procedures for managing Mental Health emergencies: 

 The VA BHHCS will identify an accessible community-based Emergency 

Department where veterans with emergent health care needs will be referred. 

 The VA BHHCS will develop agreements and arrangements for sharing 

information and financial payment with the identified community-based facility. 

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

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

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

emergency mental health evaluation. 

Recommendation 29. We recommended that the Newcastle CBOC manager establish 

a process to ensure timely notification to patients of mammography results and that this 

process is monitored for ongoing compliance. 

Concur 

Target date for completion: July 15, 2011 

VA BHHCS Diagnostic’s mammography tracking log is being modified (verification of 

completion by 7-15) to include verification that the mammography provider of service 

notifies the patients within 14 days of results in language appropriate for patients. The 

process will be monitored as part of the mammography tracking process. 

Recommendation 30. We recommended that the Mission CBOC identifies a Women’s 

Health Liaison and that collaboration occurs with the parent facility’s Women Veterans 

Program Manager. 

Concur 

VA OIG Office of Healthcare Inspections 37 
McKean, Venango, Camp Hill, Pottsville/Frackville, Mission, Newcastle, Hibbing, and Rochester 

Target date for completion: July 7, 2011 

Women’s Health Liaison has been identified and has accepted the role at the Mission 

CBOC. Facility Women Veteran’s Program Manager will collaborate with the identified 

liaison. 

Recommendation 31. We recommend that OPPEs include clinically pertinent data as 

well as performance measure compliance at the Mission and Newcastle CBOCs. 

Concur 

Target date for completion: August 1, 2011 

OPPE format for VA Staff PCP’s and Contract Staff PCP include clinically pertinent data 

and Performance Measure Compliance. Quality 23 National Performance Measure 

Metrics as follows: Compliance with the following Metrics: LDL Measure, LDL < 

100mg/dl, Retinal eye exam, Annual HgA1c measured, HgA1c <9, Weight 

Management, Depression* Screening, PTSD* Screening, Alcohol Screening and *follow 

up of positive screens. Tobacco use and intervention. 

Primary Care is developing a data base of clinical procedure (by CPT Code) listing 

common low and high risk procedures that may be requested in the C&P process. The 

data base will be used to identify specific low/high risk procedures, the number of 

specific procedures the provider completed in the past and align the past practice with 

current his/her privileges requested to validate the request or to identify training or 

competency assessment (high risk). 

Recommendation 32. We recommended that relevant provider-specific data be 

compared to aggregated data of those privileged providers who hold the same or 

comparable privileges at the Mission and Newcastle CBOCs. 

Concur 

Target date for completion: May 23, 2011 

OPPE format for VA Staff PCPs and Contract Staff PCPs include: Veteran Satisfaction 

Score (benchmarked to Network and National scores), Clinic Access (benchmarked to 

Network and National scores), Safety (unapproved abbreviations with aggregate data), 

Resource Management (Cost: Laboratory, Pharmacy & Radiology benchmarked to 

Network and National Averages). 

Recommendation 33. We recommended that scopes of practice are provider-specific, 

service-specific, and facility-specific at the Newcastle CBOC. 

Concur 

Target date for completion: October 1, 2011 

VA OIG Office of Healthcare Inspections 38 
McKean, Venango, Camp Hill, Pottsville/Frackville, Mission, Newcastle, Hibbing, and Rochester 

The Scope of Practice and the privilege forms are being revised to indicate site-specific, 

setting-specific, and provider specific. The revised physician form was approved by 

Executive Committee of the Medical Staff (ECMS) on June 27, 2011 and has been 

implemented. Midlevel practitioners (Nurse Practitioners and Physician Assistants) are 

currently revising the applicable form. Target date for completion is October 1, 2011. 

Recommendation 34. We recommended that staff receive training for required skill 

competencies and that this training is validated and documented at the Mission and 

Newcastle CBOCs. 

Concur 

Target date for completion: October 31, 2011 

An inventory of nursing procedures performed at the CBOC’s and currently utilized 

competency validation will be compiled. A gap analysis will be performed to determine 

what additional competency validation is required. A mechanism to continually assess 

and sustain the competencies of CBOC nursing staff will be developed. 

Recommendation 35. We recommended that managers ensure that all patient care 

staff members be assessed at orientation and annually to assure competence to 

perform their responsibilities for Mission and Newcastle CBOCs. 

Concur 

Target date for completion: October 31, 2011 

Current orientation, annual training requirements, and competency validation processes 

at the CBOC’s will be compiled. A gap analysis will be performed to determine what 

additional topics are required. A mechanism to continually validate the orientation, 

training, and competencies of nursing staff will be developed. Managers of the CBOCs 

will be provided guidance concerning the various components required for ensuring 

clinic staff are competent to perform their responsibilities. 

Recommendation 36. We recommended that fire drills be conducted annually at the 

Newcastle and Mission CBOCs. 

Concur 

Target date for completion: August 1, 2011 

The CBOC team (BHHCS Employees) that work in New Castle will be given 

documentation from the VA BHHCS Fire Department for completing a fire drill. The 

EOC team member reviewing fire/life safety during the semi-annual environment of care 

rounds at the CBOC’s will validate the completion of the fire drills and supply the 

documentation to the fire department. If the CBOC is unable to produce, then it 

becomes the COTR and contracting office’s responsibility to enforce the contract. 

VA OIG Office of Healthcare Inspections 39 
McKean, Venango, Camp Hill, Pottsville/Frackville, Mission, Newcastle, Hibbing, and Rochester 

Recommendation 37. We recommended that managers monitor and collect 

measurable data for hand hygiene at the Newcastle and Mission CBOCs. 

Concur 

Target date for completion: August 31, 2011 

Registered Nurse at Mission CBOC is currently collecting the data and has now 

supplied 2 months of data. Tracking and analysis of the data is available on the 

Infection Control SharePoint for all CBOC's and the other clinical sites in the 

organization. Outline of Process: 1. Collect HH at Mission. 2. Fax to Infection Control 

Coordinator Monthly 3. Receive back graph comparing performance to target, to self, 

and to VABHHCS as a whole. Similar process for surveillance will be implemented at 

Newcastle CBOC. Hand Hygiene data collected to date for Mission CBOC: 

May –40/45 observations = 89%; June – 78/120 observations = 65%. 

Recommendation 38. We recommended that the parent facility conduct a vulnerability 

risk review to assess the need for panic alarms at the Newcastle and Mission CBOCs. 

Concur 

Target date for completion: August 31, 2011 

All CBOCs under the jurisdiction of the BHHCS will be inspected before the end of 

August 2011 for FY11. Language in the assessment memos will clearly state if the risk 

for panic alarms will require their use, which up to this period has been included in the 

inspection survey worksheet for each clinic/CBOC. 

Recommendation 39. We recommended that two patient identifiers are used by staff 

when collecting blood samples at the Mission CBOC. 

Concur 

Target date for completion: July 8, 2011 

A copy of the facility patient identification policy (COS 73) will be provided to the Mission 

CBOC staff by July 8, 2011. Compliance with the policy will be validated by October 1, 

2011 through an on-site visit by parent facility staff. 

Recommendation 40. We recommended that the Mission and Newcastle CBOCs 

develop a local policy or SOP that reflects the current practice and capability for 

handling medical and MH emergencies. 

Concur 

Target date for completion: July 8, 2011 

VA OIG Office of Healthcare Inspections 40 
McKean, Venango, Camp Hill, Pottsville/Frackville, Mission, Newcastle, Hibbing, and Rochester 

Standard Operating Procedure (SOP) will be developed for by the CBOCs regarding 

Medical emergencies. An example of an appropriate SOP has been forwarded to the 

CBOC contractor. 

Recommendation 41. 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 

Target date for completion: August 31, 2011 

New PCMM coordinator is already addressing duplicate enrollees. 

Recommendation 42. We recommended that the Facility Director and Contracting 

Officer ensure the contractor complies with the required contract reporting provisions. 

Concur 

Target date for completion: July 20, 2011 

Contracting Officer will issue a letter notifying them of non-compliance and detailed 

instructions with time lines for compliance. 

VA OIG Office of Healthcare Inspections 41 
McKean, Venango, Camp Hill, Pottsville/Frackville, Mission, Newcastle, Hibbing, and Rochester 

Appendix F 

Minneapolis VA HCS Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: July 11, 2011 

From: Director, Minneapolis VA HCS (618/00) 

Subject: CBOC Reviews: Hibbing and Rochester, MN 

To: Director, VISN 23 (10N23) 

Thank you for the opportunity to provide a report on the draft findings from 

the CBOC reviews of the Hibbing and Rochester, Minnesota. I have 

reviewed the report from the site visits that occurred during the week of 

May 14, 2011. We concur with the recommendations and have already 

initiated corrective actions. 

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

recommendations in the draft report, please contact me at (612) 725­

2101. 

(original signed by:) 

STEVEN P. KLEINGLASS 

Medical Center Director, Minneapolis 

VA OIG Office of Healthcare Inspections 42 
McKean, Venango, Camp Hill, Pottsville/Frackville, Mission, Newcastle, Hibbing, and Rochester 

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 43. We recommended that a contract, sharing agreement, or other
 

appropriate arrangement is developed with the external organization for sharing
 

information when patients at the Hibbing and Rochester CBOCs are referred to a
 

community-based ED for MH emergencies.
 

Concur
 

Target date for completion: December 31, 2011
 

Mental Health and CBOC staff will develop a sharing agreement for MH services at
 

community-based Emergency Departments for MH emergencies per MH Uniform
 

Services Package.
 

Recommendation 44. We recommended that providers document a justification for the
 

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

Concur
 

Target date for completion: Complete
 

The Non-VA Care consult template was adjusted to document the justification for the
 

use of fee basis care in the medical record as a required field.
 

Recommendation 45. 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 system of record at the Rochester CBOC.
 

Concur
 

Target date for completion: Complete
 

The consult is set to automatically generate a letter to the Veteran when the consult for
 

Non-VA care services is requested. The VISTA generated letter remains in the
 

computer to ensure written notification is sent.
 

Recommendation 46. We recommended that the copies of Short-Term Fee Basis
 

mammography reports of Rochester CBOC patients are filed or scanned into the
 

radiology package in the medical record.
 

Concur
 

VA OIG Office of Healthcare Inspections 43 
McKean, Venango, Camp Hill, Pottsville/Frackville, Mission, Newcastle, Hibbing, and Rochester 

Target date for completion: Complete 

A policy was updated and processes have been modified to ensure that all 

mammogram reports are scanned into the radiology package. Radiology Package 

Delinquent Status Report is monitored on a daily basis to ensure orders are completed 

administratively for all completed studies. The policy outlines the process to ensure that 

the results are scanned in with appropriate follow up communication. 

Recommendation 47. We recommended that managers at the Hibbing and Rochester 

CBOCs establish a process to ensure effective oversight of the mammography program 

as required by VHA policy. 

Concur 

Target date for completion: Complete 

Processes have been modified to ensure that effective oversight of the mammogram 

program as required by VHA policy have been implemented (These processes and 

oversight apply to all CBOCs.) Procedural changes have already been implemented. 

In addition, a “look-back” has been conducted on all mammograms ordered in the last 

year to ensure appropriate follow-up, including scanning of all reports into the Radiology 

package with BI-Rads categories. This look-back confirmed no cases were lost to 

follow up. 

Recommendation 48. We recommended that managers at the Hibbing and Rochester 

CBOCs establish a process to ensure that all mammogram orders are entered into the 

CPRS radiology package and that all mammography results are linked to the 

appropriate order. 

Concur 

Target date for completion: Complete 

Processes have been modified to ensure that all mammogram orders are entered into 

the radiology package along with corresponding results that are appropriately linked in 

CPRS. Procedural changes have already been implemented with monitoring 

established. 

Recommendation 49. We recommended that mammography results be documented 

in BI-RADS categories at the Hibbing and Rochester CBOCs. 

Concur 

Target date for completion: Complete 

Processes have been modified to ensure that all mammogram results are entered using 

BI-RADs categories. Procedural changes have already been implemented so that 

reports of these mammograms are entered into the Radiology reports section of VistA 

VA OIG Office of Healthcare Inspections 44 
McKean, Venango, Camp Hill, Pottsville/Frackville, Mission, Newcastle, Hibbing, and Rochester 

using the outside reports section of the Radiology package. Each report will utilize the 

appropriate national diagnostic code corresponding to the “BI-RADS” assessment 

category. 

Recommendation 50. We recommended that the Professional Standards Board 

grants privileges consistent with the services provided at the Hibbing CBOC. 

Concur 

Target date for completion: October 31, 2011 

Privilege forms used by CBOC providers will be revised. These revisions will ensure 

that only privileges appropriate to the CBOC setting may be requested by providers. 

Recommendation 51. We recommended that service-specific competency criteria is 

created, approved, and implemented in advance of the start of the FPPE period for 

providers at the Hibbing and Rochester CBOCs. 

Concur 

Target date for completion: October 31, 2011 

In concert with the privilege form modification, FPPE criteria for CBOC providers will be 

developed that are tailored to the CBOC- setting and privileges being requested. The 

service-specific competency criteria will be created, approved, and implemented in 

advance of the start of the FPPE period for providers at the CBOCs. 

Recommendation 52. We recommended that all providers have a scope of practice 

that is provider-specific, service-specific, and facility-specific. 

Concur 

Target date for completion: October 31, 2011 

A review will be conducted to ensure that all providers that are under a scope of 

practice will have revisions, if need, to ensure that the scope is provider specific, service 

specific and facility specific. In some cases the templated format will be modified to 

ensure it includes the specific criteria. 

Recommendation 53. We recommended that managers ensure that all patient care 

staff members be assessed annually to assure competence to perform their 

responsibilities at the Rochester CBOC. 

Concur 

Target date for completion: Complete 

Annual competencies are required for staff members to ensure that appropriate skills 

are assessed on at least an annual basis. Modifications to the annual competencies 

VA OIG Office of Healthcare Inspections 45 
McKean, Venango, Camp Hill, Pottsville/Frackville, Mission, Newcastle, Hibbing, and Rochester 

were adjusted to include blood draw as an annual competency. All staff have 

completed the blood draw competency. Nursing staff will monitor to ensure annual 

competencies will be completed for all staff. 

Recommendation 54. We recommended that fire drills be conducted and documented 

annually at the Rochester CBOC. 

Concur 

Target date for completion: Completed 

Although the fire drill was conducted, the facility was not able to provide the 

documentation after a physical move to a new location. Processes are now in place so 

that both the parent facility Council structure Environment of Care Council receives 

confirmation of annual fire drills in addition to on sight documentation of the drill. 

Recommendation 55. We recommended that the PCMM Coordinator is in accordance 

with VHA policy to perform enrollment upon completion of the patient’s appointment and 

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

Concur 

Target date for completion: Completed 

Enrollment has been adjusted so that it is in accordance with VHA policy upon 

completion of the Veteran’s appointment. The process has been implemented so that 

the Veteran is then assigned to the new Panel and removed from the previous panel. 

Recommendation 56. We recommended that the Facility Director strengthens the 

invoice validation process to ensure the invoiced enrollees using VA data and provide 

that list of billable enrollees to the contractor. This process mitigates the risk of 

overpayments to the contractor. 

Concur 

Target date for completion: Completed 

VA data is collected and validated by the COTR prior to sending the information to the 

vendor. Internal audit process has been implemented which includes monitoring of the 

specific requirements in order to receive payment: 1) annual vesting visit, 2) progress 

note in VistA, and 3) updated means test. 

Recommendation 57. We recommended that the Facility Director and Contracting 

Officer modify the contract to comply with VHA policies. 

Concur 

Target date for completion: April 1, 2012 

VA OIG Office of Healthcare Inspections 46 
McKean, Venango, Camp Hill, Pottsville/Frackville, Mission, Newcastle, Hibbing, and Rochester 

The contract for the Hibbing CBOC is due to expire. Contracting is in process of new 

solicitation to award a new contact by April 1st, 2012, which will comply with all VHA 

policies and directives, to include the statement of work, performance measures, and 

commercial contract provisions. 

VA OIG Office of Healthcare Inspections 47 
McKean, Venango, Camp Hill, Pottsville/Frackville, Mission, Newcastle, Hibbing, and Rochester 

Appendix G 

OIG Contact and Staff Acknowledgments 

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

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

Contributors	 Nancy Albaladejo, RN 

Sheila Bezak, RN 

Gail Bozzelli, RN 

Shirley Carlile, BA 

Marisa Casado, RN 

Lin Clegg, PhD 

Marnette Dhooghe, MS 

Nathan Fong, CPA 

Stephanie Hills, RN 

Zhana Johnson, CPA 

Sandra Khan, RN 

Anthony M. Leigh, CPA 

Sarah Lutter, RN, JD 

Sami O’Neill, MA 

Noel Rees, MPA 

Jennifer Reed, RN 

Thomas J. Seluzicki, CPA 

Marilyn Stones, BS 

Ann Ver Linden, RN 

VA OIG Office of Healthcare Inspections 48 
McKean, Venango, Camp Hill, Pottsville/Frackville, Mission, Newcastle, Hibbing, and Rochester 

Appendix H 

Report Distribution 

VA Distribution 

Office of the Secretary
 

Veterans Health Administration
 

Assistant Secretaries
 

General Counsel
 

Director, VISN 4 (10N4)
 

Director, Erie VAMC (562/00)
 

Director, Lebanon VAMC (595/00)
 

Director, VISN 23 (10N23)
 

Director, VA Black Hills HCS (568/00)
 

Director, Minneapolis VA HCS (618/00)
 

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, Robert P. Casey, Jr., Michael B. Enzi, Al Franken, 

Tim Johnson, Amy Klobuchar, John Thune, Patrick J. Toomey 

U.S. House of Representatives: Chip Cravaack, Tim Holden, Cynthia M. Lummis, 

Kristi L. Noem, Todd Russell Platts, Glenn Thompson, Timothy J. Walz 

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

VA OIG Office of Healthcare Inspections 49