Department of Veterans Affairs
	

Office of Inspector General
	

Healthcare Inspection
 

Alleged Quality of Care Issues

Martinez Outpatient Clinic and Center

for Rehabilitation and Extended Care

Martinez, California

Report No. 10-02468-131 March 23, 2011
	 VA Office of Inspector General
	

Washington, DC 20420
	
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)
 
Alleged Quality of Care Issues, Martinez Outpatient Clinic and CREC, Martinez, California 

Executive Summary
	

The VA Office of Inspector General Office of Healthcare Inspections conducted an 

inspection to determine the validity of allegations regarding quality of care received by 

six patients at the Martinez Outpatient Clinic (OPC) and Center for Rehabilitation and 

Extended Care (CLC). The OPC and CLC is a part of the VA Northern California Health 

Care System (system) within Veterans Integrated Service Network (VISN) 21. The 

complainant alleged that: 

	 Five patients received inadequate postoperative care and that one patient was 

inappropriately admitted as an observation patient. 

	 The CLC lacked the infrastructure for quality care for observation patients. 

	 The OPC placed surgical outpatients in a contracted community setting with no 

nursing care after their procedures. 

We substantiated the allegations regarding inadequate care for two of the six patients 

reviewed. We also substantiated the allegation that the CLC lacked the infrastructure in 

which to provide quality care for observation patients. We determined that system 

managers took appropriate actions by discontinuing urology surgeries since May 2010 

and observation care since July 2010. Therefore, we did not make any recommendations 

regarding these allegations. 

We did not substantiate the allegation that the OPC placed surgical outpatients 

inappropriately in a contracted community setting without adequate care after their 

procedures. However, we concluded that policies need to be developed for the local 

temporary lodging or Hoptel Program, employees need to be educated about the program, 

and Gains & Losses sheets should document lodger check-ins and check-outs. 

We recommended that the System Director ensure that local temporary lodging or Hoptel 

Program policies and procedures are developed, implemented, and monitored to ensure 

compliance with Veterans Health Administration policy. 

The VISN and system Directors agreed with our findings and recommendation. The 

implementation plan is acceptable, and we will follow up on the planned actions until 

they are completed. 

VA Office of Inspector General i 
DEPARTMENT OF VETERANS AFFAIRS
	

Office of Inspector General
	

Washington, DC 20420
	

TO: Director, Sierra Pacific Network (10N21) 

SUBJECT: Healthcare Inspection – Alleged Quality of Care Issues, Martinez 

Outpatient Clinic and Center for Rehabilitation and Extended Care, 

Martinez, California 

Purpose 

The VA Office of Inspector General (OIG) Office of Healthcare Inspections received 

allegations regarding quality of care issues at the Martinez VA Outpatient Clinic (OPC) 

and Center for Rehabilitation and Extended Care (CLC) in Martinez, CA. The purpose of 

this review was to determine whether the allegations had merit. 

Background 

The OPC and CLC is a part of the VA Northern California Health Care System (system) 

within Veterans Integrated Service Network (VISN) 21. The Sacramento VA Medical 

Center is the parent facility in this system. It has 60 inpatient beds and offers a full range 

of services including medical, surgical, outpatient, and mental health. It is approximately 

79 miles from Martinez, CA. 

The OPC, a satellite outpatient clinic and freestanding ambulatory surgery center, offers 

medical, surgical, mental health, and diagnostic services and houses two operating rooms 

and two procedure rooms. Adjacent to the OPC is the 120-bed CLC that provides subacute, rehabilitation, and transitional care, as well as a 23-hour observation bed program 

for patients after ambulatory surgical procedures. The 45-bed Napa Unit, which provides 

sub-acute and skilled nursing care, houses the postoperative patients requiring 

observation.1 The CLC does not designate specific beds for observation stays; bed 

assignments are made according to availability at the time of need. 

The Veterans Health Administration (VHA) defines ambulatory surgery as “surgical or 

invasive diagnostic procedures performed by qualified providers in ambulatory or 

dedicated surgical suites with pre-procedural and immediate post-procedural care on the 

1 VHA Directive 2009-064, Recording Observation Patients, November 30, 2009. 

VA Office of Inspector General 1 
Alleged Quality of Care Issues, Martinez Outpatient Clinic and CREC, Martinez, California 

same day, or observation admissions without hospitalization.”2 Patients selected for 

ambulatory surgery should require a minimal anticipated recovery period with no 

postoperative complications expected and be discharged home with a competent adult. 

Data also needs to be collected regularly for periodic review and reporting. This includes 

any patients that require unplanned overnight observation, admission to an acute care bed 

within 14 days of the surgery due to a surgical or anesthetic complication, and deaths that 

occur within 30 days of ambulatory surgery. 

Overnight observation admissions may be required for some ambulatory surgery patients. 

An observation patient is “one who presents with a medical condition showing a 

significant degree of instability needs to be monitored and evaluated, receives ongoing 

short-term treatment assessment and reassessment while a decision is being made as to 

whether the patient requires further treatment as a hospital inpatient, will be discharged, 

or assigned to care in another setting.”3 In contrast, admission criteria for long-term care 

include medical and psychiatric stability, and the goal is to restore the resident to 

maximum function, prevent further decline, maximize independence, and/or provide 

comfort when dying. 

Local4 and VHA policy5 define minimum documentation6 for observation stays to 

include performance of an initial assessment and a history and physical examination 

immediately upon admission to the observation unit. Admission and discharge orders 

should be timed and dated. Progress notes within the observation period should include 

the condition of the patient, course of treatment, patient’s response to treatment, and 

significant findings at the time of documentation of the progress note. The discharge 

note should also include: 

1. Final diagnoses 

2. Complications 

3. Summary of the reason for the observation admission, the outcomes, and followup plans 

4. Patient disposition 

5. Discharge instructions 

On March 4, 2010, VHA further defined appropriate use of observation status for 

postoperative patients, stating that the system must assign these patients to a service with 

a clearly identified responsible attending physician. Criteria for observation status do not 

2 VHA Handbook 1102.5, Criteria and Standards for Performance of Ambulatory (Same Day) Surgery Performed in
 

Ambulatory or Dedicated Surgical Suites, May 20, 2003.
 3 VHA Directive 2009-064.
 4 VANCHCS Policy 11-3, Attachment A. Observation Program, January 19.2010.
 5

VHA Directive 2009-064, Attachment A, Observation Patient Record Documentation Requirements,
 

November 30, 2009.

6

VHA Directive 2009-064, Attachment A.
 

VA Office of Inspector General 2 
Alleged Quality of Care Issues, Martinez Outpatient Clinic and CREC, Martinez, California 

include routine recovery from procedures or surgeries. However, use of these beds for 

patients who develop short-term complications or require extended observation past the 

routine recovery time from ambulatory surgery or procedures is acceptable.7 

For ambulatory surgery patients with travel difficulties due to inclement weather or 

transportation problems, VHA specifies that the system may furnish temporary lodging or 

Hoptel services to lodgers or veterans who are housed for non-medical purposes and who 

are not receiving health care services while lodged.8 They are not patients. Local 

policies are required for temporary lodging programs that outline eligibility criteria, 

delegations of authority, and program oversight responsibilities. All staff, including new 

employees and trainees, must be familiar with the policies, and the system Gains and 

Losses (G&L) sheets should document lodger check-ins and check-outs.9 

The OIG Hotline Division received allegations that patients have not received appropriate 

care after surgeries and invasive procedures. Specifically, the complainant alleged that: 

(a) five patients received inadequate postoperative care and that one patient was 

inappropriately admitted as an observation patient, (b) the CLC lacked the infrastructure 

for quality care for observation patients, and (c) surgical outpatients were placed in a 

contracted community setting with no nursing care after their procedures. Allegations 

were also made regarding the research programs at Martinez as well as the activities of a 

respiratory therapist. These allegations were not included in this review. 

Scope and Methodology 

We interviewed the complainant in person and through telephone conversations. We 

conducted site visits on August 5 and August 18–19, 2010. We interviewed senior 

managers and employees and reviewed pertinent local documents, medical records, and 

VHA policies and procedures. 

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

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

Efficiency. 

Inspection Results 

Issue 1: Quality of Care in Selected Cases 

We substantiated the allegations of inadequate care for two of the six patients. We 

concluded that the remaining four patients were managed appropriately. 

7 VHA Directive 2010-011, Standards for Emergency Departments, Urgent Care Clinics, and Facility Observation
 

Beds, March 4, 2010.
 8 VHA Directive 2003-009, Temporary Lodging and Hoptel Programs, February 7, 2003.
 9 VHA Directive 2009-064.
 

VA Office of Inspector General 3 
Alleged Quality of Care Issues, Martinez Outpatient Clinic and CREC, Martinez, California 

Patient 1 

Case Summary. The patient, a man in his late 70s with a bladder tumor, underwent a 

transurethral resection of the bladder tumor (TURBT) in late March 2010. Prior to 

surgery, it was noted that the patient failed to follow instructions to discontinue his 

aspirin. However, the surgeon made the decision to proceed with surgery, as the 

procedure would be short. After surgery, the patient transferred to the CLC due to 

postoperative bleeding. He required continuous bladder irrigation and monitoring of his 

red blood cell levels. 

During the night, the patient continued to experience postoperative bleeding with blood 

clots noted in the urinary catheter tubing. He also complained of severe pain and 

received Vicodin® (medication used to relieve moderate to severe pain) which was 

minimally effective. Care providers did not order or administer any other pain 

medication. 

The following morning, the patient’s condition deteriorated. He was transferred to a 

community hospital due to an elevated white blood count of 27.7 (normal range: 

4.3–10.3 per microliter) and a low hemoglobin level of 7.2 (normal range: 13–18 grams 

per deciliter). The patient required blood transfusions. After a 3-day stay, the hospital 

discharged the patient in stable condition. 

Findings. We substantiated the allegation of inadequate postoperative care. The patient 

was actively bleeding and in pain. Interventions did not address underlying problems. 

The arrangements for transfer to a higher level of care did not take place until 24 hours 

after surgery. We noted that the system halted all urology surgeries at the OPC since 

May 28, 2010. 

Care providers did not adequately document the patient’s post-procedure condition and 

health care team members’ communications in the medical record. The surgeon dictated 

the operative report more than 2 weeks after surgery.10 System leadership acknowledged 

that medical record documentation, including a timely operative report and 

documentation of post-procedural care and communication between health team 

members needed to be improved. 

Patient 2 

Case Summary. The patient is a man in his late 70s with a bladder tumor and a history of 

congestive heart failure, hypertension, and a positive cardiac surgical history requiring an 

automatic implantable cardioverter defibrillator.11 The patient withheld his doses of 

10 VHA Handbook 1102.5.
 11 An automatic implantable cardioverter defibrillator (AICD) is a device that monitors heart rhythms with leads in
 

the right atrium and right ventricle; it delivers an electrical shock when a dangerous rhythm is detected.
 

VA Office of Inspector General 4 
Alleged Quality of Care Issues, Martinez Outpatient Clinic and CREC, Martinez, California 

warfarin (medication to prevent blood from clotting) for 5 days prior to his January 2010 

surgery as instructed and took subcutaneous enoxaparin as bridging therapy.12 

In mid-January 2010, the patient underwent a TURBT. Postoperatively, he transferred to 

the CLC for a 23-hour observation stay.13 During the night, the patient had cranberrycolored urine and required an oral dose of pain medication. 

The following morning, the patient had blood clots in the urinary catheter tubing, and the 

nurses initiated bladder irrigations as ordered. The health care team arranged to admit the 

patient to the CLC for continued nursing care. The lowest hemoglobin level during this 

postoperative period was within normal limits, and the patient did not require any 

transfusions. 

On postoperative day 3, the blood clots had resolved. The patient urinated without 

difficulty and was discharged home with oral antibiotics, warfarin, and enoxaparin and 

instructed to follow up with the urology clinic. That evening, the patient had difficulty 

urinating and called the VISN 21 Telephone Care Line. The nurse instructed the patient 

to present to the nearest emergency department. 

During the next 2 weeks, the patient required admission to two community hospitals for 

clot retention requiring bladder irrigation and for chest pain with diagnosis and treatment 

of a mild myocardial infarction (heart attack). The patient has since stabilized and been 

scheduled for ongoing outpatient urological care at the OPC. 

Findings. We substantiated the allegation of inadequate postoperative care for this 

patient. The patient required more intensive monitoring for the development of blood 

clots in an acute care setting. He was not seen by a physician during the 2 days prior to 

discharge. We noted that the system formally reviewed this case and halted all urology 

surgeries at the OPC since May 28, 2010. 

Patient 3 

Case Summary. The patient, a man in his 60s, underwent a colonoscopy with biopsies 

and removal of polyps under moderate sedation in late April 2010. After the procedure, 

the patient transferred to the CLC for observation due to lack of transportation home. He 

also complained of abdominal pain and right-sided tenderness. The gastroenterologist 

ordered a computed tomography (CT) scan (a special type of x-ray) and an abdominal 

x-ray. 

Later that afternoon, 2 hours after the colonoscopy, CT scan showed a small colonic 

perforation (hole or tear in the wall of the colon). Within 2.5 hours of the discovery of 

12 Bridging therapy is the practice of protecting a patient from blood clots where enoxaparin, a low molecular weight 

heparin, is substituted for warfarin 5 days before surgery because its effects are shorter in duration.

13 VHA Directive 2009-064. 

VA Office of Inspector General 5 
Alleged Quality of Care Issues, Martinez Outpatient Clinic and CREC, Martinez, California 

the micro-perforation, the CLC transferred the patient to a community hospital for 

continued monitoring and care. The patient did not require surgical intervention, and the 

hospital discharged him after a short uneventful stay. 

Findings. We did not substantiate the allegation of inadequate post procedural care in 

this case. We determined that the CLC quickly and efficiently transferred the patient to a 

higher level of care once the need for acute care monitoring was evident. The system 

also thoroughly reviewed the outcomes of the colonoscopy and the events leading up to 

the patient’s transfer to community hospital to ensure that the patient’s care met 

community standards. 

Patient 4 

Case Summary. The patient, a male in his late 60s with a history of peripheral vascular 

disease, bilateral lower extremity bypass grafts, and benign prostate enlargement, 

underwent a cystoscopy with biopsies to rule out a bladder tumor in early February 2010. 

Postoperatively, the patient had rose-colored urine and transferred to the CLC for a 

23-hour observation stay. 

The patient received intravenous (IV) antibiotics and oral pain medications during the 

overnight stay. The following morning, the urine cleared, and the CLC discharged the 

patient with instructions for a follow-up urology clinic appointment in a week. 

Findings. We did not substantiate the allegation of inadequate care in this case. The 

patient received IV antibiotics as ordered. The health care team observed him during the 

overnight stay and then discharged him in stable condition. The patient did not have any 

adverse occurrences during the immediate or remote postoperative period. 

Patient 5 

Case Summary. The patient, a man in his 20s with a history of traumatic brain injury, 

was seen in the Urgent Care Clinic (UCC) in early March 2010 for acute bacterial throat 

infection. The physician admitted the patient to the CLC for a 23-hour observation stay 

and ordered IV antibiotics. The patient was not able to tolerate anything more than a 

liquid diet during the stay and needed IV morphine for pain. 

Immediately after discharge from the CLC, the UCC physician examined the patient and 

gave him a referral to the otolaryngology (ENT) clinic for follow-up. Discharge 

medications included oral antibiotics. Almost 3 weeks later, the ENT physician 

examined the patient, and considered the condition resolved. 

Findings. We did not substantiate the allegation that this patient received inadequate 

care. His acute throat infection required the initiation of IV antibiotics in a 23-hour 

observation setting. The CLC discharged the patient appropriately on oral antibiotics the 

VA Office of Inspector General 6 
Alleged Quality of Care Issues, Martinez Outpatient Clinic and CREC, Martinez, California 

following day. 

improved. 

Outpatient follow-up care was provided, and the patient’s condition 

Patient 6 

Case Summary. 

mid-July 2010. 

The patient, a man in his early 60s, underwent sinus surgery in 

During surgery, the surgeon discovered and promptly repaired a 

cerebrospinal fluid leak. The health care team monitored the patient in the postoperative 

recovery area and found him to be neurologically intact and medically stable. The 

surgeons transferred the patient to the parent facility for prophylactic IV antibiotics, 

observation, and activity restriction (no nose blowing, straining, or coughing). 

After transfer, a head CT scan showed pneumocephalus.14 The remainder of the patient’s 

postoperative course was uneventful. Symptoms improved while the surgeons followed 

his progress and provided ongoing care. The parent facility discharged the patient after a 

2-day stay with a follow-up appointment in a week. 

Findings. We did not substantiate the allegation of inadequate postoperative care. We 

determined that the system quickly and efficiently transferred the patient to a higher level 

of care postoperatively. The patient was determined to be stable and did not require 

transfer to the nearest community hospital. The transfer to the parent facility allowed the 

surgical team to continue monitoring and caring for the patient in an acute care setting. 

Issue 2: Infrastructure for Observation Care 

We substantiated the allegation that the CLC lacked the infrastructure in which to provide 

quality care for observation patients. We determined that urologists have pre-arranged 

for 23-hour observation stays for surgical patients regardless of the occurrence of 

complications during surgery. Although the CLC nursing staff had documented 

competencies for the basic care of surgical patients, the nurse staffing ratios did not 

support the needs of potentially unstable surgical observation patients. We noted 

inconsistencies with VHA requirements in the medical record documentation in three of 

the five observation patient records reviewed. Table 1 below shows the deficiencies. 

Table 1. Medical Record Reviews 

Case #1 Case #2 Case #3 Case #4 Case #5 

Initial Assessment Yes No Yes No Yes 

History & Physical Yes No Yes Yes No 

Admission Orders Yes Yes Yes Yes Yes 

Discharge Orders Yes Yes Yes No Yes 

Progress Note Yes No Yes Yes No 

Discharge Note (with all 

required components) Yes Yes Yes Yes No 

14 This is the presence of air in the skull. This condition often resolves without additional intervention. 

VA Office of Inspector General 7 
Alleged Quality of Care Issues, Martinez Outpatient Clinic and CREC, Martinez, California 

Also, according to VHA policy,15 observation patients “must be assigned a treating 

specialty code of observation...and that all services and costs associated with the 

observation treating specialty are captured and assigned to inpatient services.” This 

process was not in place as we found that the names of observation patients were handwritten by nurses into a unit notebook instead of being systematically and officially 

recorded in the G&L sheets for administrative workload monitoring and tracking. 

Issue 3: Disposition of Patients 

We did not substantiate the allegation that the OPC inappropriately placed surgical 

outpatients in a contracted community setting without adequate care after their 

procedures. However, the system needs to strengthen administrative and educational 

processes. Local policies are required for temporary lodging programs, which outline 

eligibility criteria, delegations of authority, and program oversight responsibilities. All 

staff, including new employees and trainees, must be familiar with the policies, and the 

system G&L sheets should document lodger check-ins and check-outs.16 

We found that the OPC places lodgers in available CLC beds and uses a nearby hotel for 

overflow when CLC beds not available. However, the OPC and CLC were unable to 

provide policies and procedures about the local temporary lodging and Hoptel program, 

and did not document lodger check-ins and check-outs in the G&L sheets. In addition, 

not all employees understand the difference between lodgers and observation patients. 

There is a perception that the OPC inappropriately sends observation patients requiring 

nursing care to the nearby hotel after surgery when in fact, these lodgers require no health 

care services. 

Conclusions 

We substantiated the allegations regarding inadequate care for two of the six patients 

reviewed. We also substantiated the allegation that the CLC lacked the infrastructure in 

which to provide quality care for observation patients. We determined that system 

managers took appropriate actions by discontinuing urology surgeries since May 2010 

and observation care since July 2010. Therefore, we did not make any recommendations 

regarding these allegations. 

We did not substantiate the allegation that the OPC placed surgical outpatients 

inappropriately in a contracted community setting without adequate care after their 

procedures. However, we concluded that policies and procedures need to be developed 

for the local Hoptel Program, employees need to be educated about the program, and 

G&L sheets should document lodger check-ins and check-outs. 

15 VHA Directive 2009-064. 

16 VHA Directive 2009-064. 

VA Office of Inspector General 8 
Alleged Quality of Care Issues, Martinez Outpatient Clinic and CREC, Martinez, California 

Recommendation 

We recommended that the system Director ensures that local Hoptel Program policies 

and procedures are developed, implemented, and monitored to ensure compliance with 

VHA policy. 

Comments 

The VISN and system Directors agreed with our findings and recommendation (see 

Appendixes A and B, pages 10–12, for the Director’s comments). The implementation 

plan is acceptable, and we will follow up on the planned actions until they are completed. 

 (original signed by:)

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

Assistant Inspector General for
 

Healthcare Inspections
 

VA Office of Inspector General 9 
Alleged Quality of Care Issues, Martinez Outpatient Clinic and CREC, Martinez, California 

Appendix A 

VISN Director Comments 

Department of 

Veterans Affairs Memorandum 

Date:	 March 9, 2011 

From:	 Director, Sierra Pacific Network (10N21) 

Subject:	 Healthcare Inspection – Alleged Quality of Care Issues,

Martinez Outpatient Clinic and Center for Rehabilitation and

Extended Care, Martinez, California

To:	 Director, Los Angeles Office of Healthcare Inspections (54LA) 

Thru:	 Director, Management Review Service (10B5) 

1.	 Thank you for the opportunity to review the draft report 

on the Alleged Quality of Care Issues, Martinez 

Outpatient Clinic and Center for Rehabilitation and 

Extended Care, Martinez, California. We concur with the 

recommendation, and will ensure completion as described 

in the attached plan by the established target date. 

2. If you have any questions regarding the attached response 

or action for the recommendation in the draft report, 

please contact Ms. Judy Daley, VISN 21 Quality 

Management Officer, at (775) 328-1774. 

(original signed by:) 

Sheila M. Cullen
 

Director, Sierra Pacific Network (10N21)
 

VA Office of Inspector General 10 
Alleged Quality of Care Issues, Martinez Outpatient Clinic and CREC, Martinez, California 

Appendix B 

System Director Comments 

Department of 

Veterans Affairs Memorandum 

Date:	 March 9, 2011 

From:	 Director, VA Northern California Health Care System (612/00) 

Subject:	 Healthcare Inspection – Alleged Quality of Care Issues,

Martinez Outpatient Clinic and Center for Rehabilitation and

Extended Care, Martinez, California

To:	 Director, Sierra Pacific Network (10N21) 

1. On behalf	 of the VA Northern California Health Care 

System, I would like to thank you for the informative and 

constructive Health Care Inspection for Alleged Quality of 

Care Issues at the Martinez Outpatient Clinic and Center 

for Rehabilitation and Extended Care, Martinez, 

California. Attached, you will find our corrective action 

plan and target completion date for the recommendation. 

2. If you	 have questions or need additional information, 

please feel free to contact Cynthia Knell, Quality 

Manager, at (916) 843-9290. 

(original signed by:) 

Brian J. O’Neill, MD
 

Director, VA Northern California Health Care System (612/00)
 

VA Office of Inspector General 11 
Alleged Quality of Care Issues, Martinez Outpatient Clinic and CREC, Martinez, California 

Director’s Comments
	

to Office of Inspector General’s Report
	

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

recommendations in the Office of Inspector General’s report: 

OIG Recommendation

We recommended that the System Director ensures that local Hoptel 

Program policies and procedures are developed, implemented, and 

monitored to ensure compliance with VHA policy. 

Concur Target Completion Date: April 11, 2011 

Facility’s Response:

The Quality Manager, Chief of Staff, and Associate Director of Patient 

Care Services will ensure development of a policy and education of staff to 

encompass a Hoptel Program for VANCHCS [the system]. 

The developed policy will incorporate eligibility criteria, delegations of 

authority, and program oversight responsibilities. 

The Chief of BDMS [Benefit and Data Management Service] will conduct 

a quarterly audit of the Gains and Losses sheets to demonstrate compliance 

with documentation of lodger check-ins and check-outs. The audit data 

will be presented and analyzed quarterly at the Provision of Care 

Committee. 

Status: Open 

VA Office of Inspector General 12 
Alleged Quality of Care Issues, Martinez Outpatient Clinic and CREC, Martinez, California 

Appendix C 

OIG Contact and Staff Acknowledgments 

OIG Contact	 Daisy Arugay, Director 

Los Angeles Office of Healthcare Inspections 

Acknowledgments	 Mary Toy, RN, Associate Director, Team Leader 

Simonette Reyes, RN 

Kathleen Shimoda, RN 

George Wesley, MD 

Robert Yang, MD 

VA Office of Inspector General 13 
Alleged Quality of Care Issues, Martinez Outpatient Clinic and CREC, Martinez, California 

Appendix D 

Report Distribution
	

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, Sierra Pacific Network (10N21) 

Director, VA Northern California Health Care System (612/00) 

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: Barbara Boxer, Dianne Feinstein 

U.S. House of Representatives: John Garamendi, Daniel Lungren, George Miller 

VA Office of Inspector General 14