Department of Veterans Affairs 

Office of Inspector General 

Office of Healthcare Inspections 

Report No. 14-00938-272 

Community Based Outpatient Clinic 

and Primary Care Clinic Reviews 

at 

Minneapolis VA Health Care System 

Minneapolis, Minnesota 

September 8, 2014 

Washington, DC 20420 
To Report Suspected Wrongdoing in VA Programs and Operations 

Telephone: 1-800-488-8244 

E-Mail: vaoighotline@va.gov 

(Hotline Information: www.va.gov/oig/hotline) 
CBOC and PCC Reviews at Minneapolis VA Health Care System, Minneapolis, MN 

Glossary 

AUD alcohol use disorder 

CBOC community based outpatient clinic 

DWHP designated women’s health provider 

EHR electronic health record 

EOC environment of care 

FY fiscal year 

MH mental health 

MM medication management 

NM not met 

OIG Office of Inspector General 

PACT Patient Aligned Care Teams 

PCC primary care clinic 

PCMM Primary Care Management Module 

PCP primary care provider 

RN registered nurse 

VHA Veterans Health Administration 

VISN Veterans Integrated Service Network 

WH women’s health 

VA OIG Office of Healthcare Inspections 
CBOC and PCC Reviews at Minneapolis VA Health Care System, Minneapolis, MN 

Table of Contents 

Page 

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

Objectives, Scope, and Methodology....................................................................... 1
 

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

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

Methodology ........................................................................................................... 1
 

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

EOC ........................................................................................................................ 3
 

AUD ........................................................................................................................ 5
 

MM .......................................................................................................................... 7
 

DWHP Proficiency .................................................................................................. 8
 

Appendixes 

A. CBOC Profiles and Services Provided .............................................................. 9
 

B. PACT Compass Metrics .................................................................................... 11
 

C. VISN Director Comments .................................................................................. 15
 

D. Facility Director Comments ............................................................................... 16
 

E. OIG Contact and Staff Acknowledgments ......................................................... 20
 

F. Report Distribution ............................................................................................. 21
 

G. Endnotes ........................................................................................................... 22
 

VA OIG Office of Healthcare Inspections 
CBOC and PCC Reviews at Minneapolis VA Health Care System, Minneapolis, MN 

Executive Summary 

Review Purpose: The purpose of the review was to evaluate selected patient care 

activities to determine whether the community based outpatient clinics (CBOCs) and 

primary care clinics (PCCs) provide safe, consistent, and high-quality health care for our 

veterans. We conducted site visits during the week of July 28, 2014, at the following 

CBOCs which are under the oversight of the Minneapolis VA Health Care System and 

Veterans Integrated Service Network 23: 

 Maplewood CBOC, Maplewood, MN 

 Twin Ports CBOC, Superior, WI 

Review Results: We conducted four focused reviews and had no findings for the 

Environment of Care review. However, we made recommendations in the following 

three review areas: 

Alcohol Use Disorder. Ensure that CBOC/PCC: 

	 Staff provide education and counseling for patients with positive alcohol screens and 

drinking alcohol above National Institute on Alcohol Abuse and Alcoholism limits. 

	 Staff consistently document the offer of further treatment to patients diagnosed with 

alcohol dependence. 

	 Managers ensure that patients with excessive persistent alcohol use receive brief 

treatment or are evaluated by a specialty provider within 2 weeks of the screening. 

	 Registered Nurse Care Managers receive motivational interviewing and health 

coaching training within 12 months of appointment to Patient Aligned Care Teams. 

Medication Management. Ensure that CBOC/PCC staff: 

	 Document that medication reconciliation was completed at each episode of care 

where the newly prescribed fluoroquinolone was administered, prescribed, or 

modified. 

	 Provide medication counseling/education as required. 

Designated Women’s Health Providers’ Proficiency. Ensure that all Designated 

Women’s Health Providers: 

	 Maintain proficiency as required for the provision of women’s health care. 

	 Are designated with the women’s health indicator in the Primary Care Management 

Module. 

VA OIG Office of Healthcare Inspections i 
CBOC and PCC Reviews at Minneapolis VA Health Care System, Minneapolis, MN 

Comments 

The VISN and Facility Directors agreed with the CBOC and PCC review findings and 

recommendations and provided acceptable improvement plans. (See Appendixes C 

and D, pages 15–19, for the full text of the Directors’ comments.) We will follow up on 

the planned actions until they are completed. 

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

Assistant Inspector General for 

Healthcare Inspections
 

VA OIG Office of Healthcare Inspections ii 
 

CBOC and PCC Reviews at Minneapolis VA Health Care System, Minneapolis, MN 

Objectives, Scope, and Methodology 

Objectives 

The CBOC and PCC reviews are an element of the OIG’s efforts to ensure that our 

Nation’s veterans receive high-quality VA health care services. As such, the CBOC and 

PCC reviews are recurring evaluations of selected primary care operations that focus on 

patient care quality and the EOC. In general, our objectives are to: 

	 Determine whether the CBOCs are compliant with EOC requirements. 

	 Determine whether CBOCs/PCCs are compliant with VHA requirements in the 

care of patients with AUD. 

	 Determine compliance with requirements for the clinical oversight and patient 

education of fluoroquinolones for outpatients. 

	 Evaluate if processes are in place for DWHPs to maintain proficiency in WH. 

Scope 

To evaluate for compliance with requirements related to patient care quality and the 

EOC, we conducted onsite inspections, reviewed clinical and administrative records, 

and discussed processes and validated findings with managers and employees. The 

review covered the following four activities: 

	 EOC 

	 AUD 

	 MM 

	 DWHP Proficiency 

The scope of this review is limited to the established objectives. Issues and concerns 

that come to our attention that are outside the scope of this standardized inspection will 

be reviewed and referred accordingly. 

Methodology 

The onsite EOC inspections were conducted at randomly selected CBOCs that had not 

been previously inspected.1 Details of the targeted study populations for the AUD, MM, 

and DWHP Proficiency focused reviews are noted in Table 1. 

1

 Includes 93 CBOCs in operation before March 31, 2013. 

VA OIG Office of Healthcare Inspections 1 
 

CBOC and PCC Reviews at Minneapolis VA Health Care System, Minneapolis, MN 

Table 1. CBOC/PCC Focused Reviews and Study Populations 

Review Topic Study Population 

AUD All CBOC and PCC patients screened within the study period 

of July 1, 2012, through June 30, 2013, and who had a positive 

AUDIT-C score2

 and all providers and RN Care Managers 

assigned to PACT prior to October 1, 2012. 

MM All outpatients with an original prescription ordered for one of 

the three selected fluoroquinolones from July 1, 2012, through 

June 30, 2013. 

DWHP Proficiencies All WH PCPs designated as DWHPs as of October 1, 2012, 

and who remained as DWHPs until September 30, 2013. 

In this report, we make recommendations for improvement. Recommendations pertain 

to issues that are significant enough to be monitored by the OIG until corrective actions 

are implemented. 

The review was done in accordance with OIG standard operating procedures for CBOC 

and PCC reviews. 

2

 The AUDIT-C is a brief alcohol screen that reliably identifies patients who are hazardous drinkers or have active 

alcohol use disorders. Scores range from 0–12. 

VA OIG Office of Healthcare Inspections 2 
 

CBOC and PCC Reviews at Minneapolis VA Health Care System, Minneapolis, MN 

Results and Recommendations 

EOC 

The purpose of this review was to evaluate whether CBOC managers have established and 

maintained a safe and clean EOC as required.a 

We reviewed relevant documents and conducted physical inspections of the Maplewood and 

Twin Ports CBOCs. The table below shows the areas reviewed for this topic. The facility 

generally met requirements. We made no recommendations. 

Table 2. EOC 

NM Areas Reviewed Findings 

The CBOC’s location is clearly identifiable 

from the street as a VA CBOC. 

The CBOC has interior signage available that 

clearly identifies the route to and location of 

the clinic entrance. 

The CBOC is Americans with Disabilities Act 

accessible. 

The furnishings are clean and in good repair. 

The CBOC is clean. 

The CBOC maintains a written, current 

inventory of hazardous materials and waste 

that it uses, stores, or generates. 

An alarm system and/or panic buttons are 

installed and tested in high-risk areas (e.g., 

MH clinic). 

Alcohol hand wash or soap dispenser and 

sink are available in the examination rooms. 

Sharps containers are secured. 

Safety needle devices are available. 

The CBOC has a separate storage room for 

storing medical (infectious) waste. 

The CBOC conducts fire drills at least every 

12 months. 

Means of egress from the building are 

unobstructed. 

Access to fire alarm pull stations is 

unobstructed. 

Access to fire extinguishers is unobstructed. 

The CBOC has signs identifying the locations 

of fire extinguishers. 

Exit signs are visible from any direction. 

No expired medications were noted during the 

onsite visit. 

VA OIG Office of Healthcare Inspections 3 
CBOC and PCC Reviews at Minneapolis VA Health Care System, Minneapolis, MN 

NM Areas Reviewed (continued) Findings 

All medications are secured from 

unauthorized access. 

Personally identifiable information is protected 

on laboratory specimens during transport so 

that patient privacy is maintained. 

Adequate privacy is provided to patients in 

examination rooms. 

Documents containing patient-identifiable 

information are not laying around, visible, or 

unsecured. 

Window coverings provide privacy. 

The CBOC has a designated examination 

room for women veterans. 

Adequate privacy is provided to women 

veterans in the examination room. 

The information technology network 

room/server closet is locked. 

All computer screens are locked when not in 

use. 

Staff use privacy screens on monitors to 

prevent unauthorized viewing in high-traffic 

areas. 

EOC rounds are conducted semi-annually (at 

least twice in a 12-month period) and 

deficiencies are reported to and tracked by the 

EOC Committee until resolution. 

The CBOC has an automated external 

defibrillator. 

Safety inspections are performed on the 

CBOC medical equipment in accordance with 

Joint Commission standards. 

The parent facility includes the CBOC in 

required education, training, planning, and 

participation leading up to the annual disaster 

exercise. 

The parent facility’s Emergency Management 

Committee evaluates CBOC emergency 

preparedness activities, participation in annual 

disaster exercise, and staff training/education 

relating to emergency preparedness 

requirements. 

VA OIG Office of Healthcare Inspections 4 
CBOC and PCC Reviews at Minneapolis VA Health Care System, Minneapolis, MN 

AUD 

The purpose of this review was to determine whether the facility’s CBOCs and PCCs complied 

with selected alcohol use screening and treatment requirements.b 

We reviewed relevant documents. We also reviewed 39 EHRs and validated findings with key 

managers and staff. The table below shows the areas reviewed for this topic. The areas 

marked as NM did not meet applicable requirements and needed improvement. 

Table 3. AUD 

NM Areas Reviewed 

Alcohol use screenings are completed during 

new patient encounters, and at least annually. 

Findings 

Diagnostic assessments are completed for 

patients with a positive alcohol screen. 

X Education and counseling about drinking 

levels and adverse consequences of heavy 

drinking are provided for patients with positive 

alcohol screens and drinking levels above 

National Institute on Alcohol Abuse and 

Alcoholism guidelines. 

Staff did not provide education and counseling 

for 2 of 11 patients who had positive alcohol use 

screens. 

X Documentation reflects the offer of further 

treatment for patients diagnosed with alcohol 

dependence. 

We did not find documentation of the offer of 

further treatment for two of six patients 

diagnosed with alcohol dependence. 

For patients with AUD who decline referral to 

specialty care, CBOC/PCC staff monitored 

them and their alcohol use. 

X Counseling, education, and brief treatments 

for AUD are provided within 2 weeks of 

positive screening. 

Treatment was not provided within 2 weeks of 

positive screening for two of eight patients. 

X CBOC/PCC RN Care Managers have 

received motivational interviewing training 

within 12 months of appointment to PACT. 

We found that 21 (39 percent) of 54 RN Care 

Managers did not receive motivational 

interviewing training within 

12 months of appointment to PACT. 

X CBOC/PCC RN Care Managers have 

received VHA National Center for Health 

Promotion and Disease Prevention-approved 

health coaching training (most likely TEACH 

for Success) within 12 months of appointment 

to PACT. 

We found that 10 (19 percent) of 54 RN Care 

Managers did not receive health coaching 

training within 12 months of appointment to 

PACT. 

The facility complied with any additional 

elements required by VHA or local policy. 

Recommendations 

1. We recommended that CBOC/Primary Care Clinic staff provide education and counseling 

for patients with positive alcohol screens and drinking alcohol above National Institute on 

Alcohol Abuse and Alcoholism limits. 

VA OIG Office of Healthcare Inspections 5 
CBOC and PCC Reviews at Minneapolis VA Health Care System, Minneapolis, MN 

2. We recommended that CBOC/Primary Care Clinic staff consistently document the offer of 

further treatment to patients diagnosed with alcohol dependence. 

3. We recommended that managers ensure that patients with excessive persistent alcohol use 

receive brief treatment or are evaluated by a specialty provider within 2 weeks of the screening. 

4. We recommended that CBOC/Primary Care Clinic Registered Nurse Care Managers 

receive motivational interviewing and health coaching training within 12 months of appointment 

to Patient Aligned Care Teams. 

VA OIG Office of Healthcare Inspections 6 
CBOC and PCC Reviews at Minneapolis VA Health Care System, Minneapolis, MN 

MM 

The purpose of this review was to determine whether appropriate clinical oversight and 

education were provided to outpatients prescribed oral fluoroquinolone antibiotics.c 

We reviewed relevant documents. We also reviewed 39 EHRs and validated findings with key 

managers and staff. The table below shows the areas reviewed for this topic. The areas 

marked as NM did not meet applicable requirements and needed improvement. 

Table 4. Fluoroquinolones 

NM Areas Reviewed Findings 

X Clinicians documented the medication 

reconciliation process that included the 

fluoroquinolone. 

We did not find documentation that medication 

reconciliation included the newly prescribed 

fluoroquinolone in 5 (13 percent) of 39 patients’ 

EHRs. 

Written information on the patient’s prescribed 

medications was provided at the end of the 

outpatient encounter. 

X Medication counseling/education for the 

fluoroquinolone was documented in the 

patients’ EHRs. 

We did not find documentation of medication 

counseling that included the fluoroquinolone in 

5 (13 percent) of 39 patients’ EHRs. 

Clinicians documented the evaluation of each 

patient’s level of understanding for the 

education provided. 

The facility complied with local policy. 

Recommendations 

5. We recommended that staff document that medication reconciliation was completed at each 

episode of care where the newly prescribed fluoroquinolone was administered, prescribed, or 

modified. 

6. We recommended that staff provide medication counseling/education as required. 

VA OIG Office of Healthcare Inspections 7 
CBOC and PCC Reviews at Minneapolis VA Health Care System, Minneapolis, MN 

DWHP Proficiency 

The purpose of this review was to determine whether the facility’s CBOCs and PCCs complied 

with selected DWHP proficiency requirements.d 

We reviewed the facility self-assessment, VHA and local policies, PCMM data, and supporting 

documentation for DWHPs’ proficiencies. The table below shows the areas reviewed for this 

topic. The areas marked as NM did not meet applicable requirements and needed 

improvement. 

Table 5. DWHP Proficiency 

NM Areas Reviewed Findings 

X CBOC and PCC DWHPs maintained 

proficiency requirements. 

We found that 5 of 18 DWHPs with panels 

comprised of less than 10 percent women 

veterans at the CBOC and/or PCCs did not have 

evidence of implementation of alternative plans 

to ensure ongoing proficiency in WH care. 

X CBOC and PCC DWHPs were designated 

with the WH indicator in the PCMM. 

We found that 22 of 27 DWHPs were not 

designated with the WH indicator in the PCMM. 

Recommendations 

7. We recommended that clinical executive/primary care leaders ensure that CBOC/Primary 

Care Clinic Designated Women’s Health Providers maintain proficiency as required for the 

provision of women’s health care. 

8. We recommended that the chief of staff consistently ensure that all Designated Women’s 

Health Providers are designated with the women’s health indicator in the Primary Care 

Management Module. 

VA OIG Office of Healthcare Inspections 8 
CBOC and PCC Reviews at Minneapolis VA Health Care S

CBOC Profiles 

This review evaluates the quality of care provided to veterans at all of the CBOCs under the parent The table below provides information relative to each of the CBOCs. 

 Uniques4 En

Location State Station # Locality5 CBOC Size6 MH7 PC8 Other9 All MH7 PC

Northwest Metro, Ramsey MN 618GI Rural Large 940 4,376 5,849 7,443 5,701 9,2

Twin Ports, Superior WI 618BY Urban Large 1,371 5,869 5,639 6,371 7,462 15,2

Rochester MN 618GG Urban Mid-Size 803 3,842 1,364 4,129 3,574 7,4

Chippewa Valley, Chippewa Falls WI 618GE Urban Mid-Size 645 3,835 1,178 4,059 4,496 8,2

Maplewood MN 618GD Urban Mid-Size 444 3,617 1,266 3,861 2,058 6,4

South Central, St. James MN 618GA Urban Mid-Size 654 3,507 1,482 3,673 3,441 9,4

Hayward WI 618GH Rural Mid-Size 420 3,439 665 3,527 2,052 8,6

Hibbing MN 618GB Rural Mid-Size 447 3,400 554 3,458 2,129 6,6

3 Includes all CBOCs in operation before March 31, 2013. 4 Unique patients and Total Encounters – Source: MedSAS outpatient files; completed outpatient appointments indicated by a valid stop 

October 1, 2012, through September 30, 2013, timeframe at the specified CBOC.

5 http://vaww.pssg.med.va.gov/PSSG/DVDC/FY2013_Q1_VAST.xlsx6 Based on the number of unique patients seen as defined by VHA Handbook 1160.01, Uniform Mental Health Services in VA Medical 

September 11, 2008, the size of the CBOC facility is categorized as very large (> 10,000), large (5,000-10,000), mid-size (1,500-5,000)

7 Mental Health includes stop codes in the 500 series, excluding 531 and 563, in the primary position. 8 Primary Care includes the stop code list in the primary position: 323 – Primary Care; 322 – Women’s Clinic; 348 – Primary Care Gro

Primary Care; 531 – MH Primary Care Team-Individual; 563 – MH Primary Care Team-Group; 170 – Home Based Primary Care (HB

9 All other non-Primary Care and non-MH stop codes in the primary position.

VA OIG Office of Healthcare Inspections 
   

 

CBOC and PCC Reviews at Minneapolis VA Health Care Systems, Minneapolis, MN 

CBOC Services Provided 

In addition to primary care integrated with WH and MH care, the CBOCs provide various 

specialty care, ancillary, and tele-health services. The following table lists the services 

provided at each CBOC.10 

CBOC Specialty Care

Services11 Ancillary Services12 Tele-Health 

Services13 

Northwest Metro Dental 

Ophthalmology 

Optometry 

Immunology 

Audiology 

MOVE! Program14 

Electrocardiography 

Nutrition 

Pharmacy 

Tele Primary Care 

Twin Ports Nephrology Laboratory 

Pharmacy 

Audiology 

Electrocardiography 

Tele Primary Care 

Rochester --- MOVE! Program 

Electrocardiography 

Tele Primary Care 

Chippewa Valley --- MOVE! Program 

Social Work 

Electrocardiography 

Tele Primary Care 

Tele Case 

Management 

Maplewood --- MOVE! Program 

Electrocardiography 

Tele Primary Care 

South Central --- Electrocardiography Tele Primary Care 

Hayward --- Electrocardiography 

MOVE! Program 

Social Work 

---

Hibbing --- --- Tele Primary Care 

10 Source: MedSAS outpatient files; the denoted Specialty Care and Ancillary Services are limited to Primary Clinic 

Stops with a count ≥ 100 encounters during the October 1, 2012, through September 30, 2013, timeframe at the 

specified CBOC.

11 Specialty Care Services refer to non-Primary Care and non-MH services provided by a physician.
 12 Ancillary Services refer to non-Primary Care and non-MH services that are not provided by a physician. 13 Tele-Health Services refer to services provided under the VA Telehealth program (http://www.telehealth.va.gov/) 14 VHA Handbook 1120.01, MOVE! Weight Management Program for Veterans, March 31, 2011. 

VA OIG Office of Healthcare Inspections 10 
CBOC and PCC Reviews at Minneapolis VA Health Care S

PACT Compass Metrics 

Data Definition.e The average waiting time in days until the next third open appointment slot for completed primary care appoint

Completed appointments in stop code 350 for this metric include completed appointments where a 350 stop code is in the primary pos

or one of the telephone stop codes is in the primary position, and 350 stop code is in the secondary position. The data is averaged 

division level. VA OIG Office of Healthcare Inspections 
CBOC and PCC Reviews at Minneapolis VA Health Care S

Data Definition.e The percent of patients scheduled within 7 days of the desired date. Data source is the Wait Times Prospective Wait 

total number of scheduled appointments for primary care-assigned patients in primary care clinics 322, 323 and 350. Data is collected and the 15th. Data reported is for the data pulled on the 15th of the month. There is no FY to date score for this measure. VA OIG Office of Healthcare Inspections 
CBOC and PCC Reviews at Minneapolis VA Health Care S

Data Definition.e This is a measure of where the patient receives his or her primary care and by whom. A low percentage is better. T

VHA ER/Urgent Care/FEE ER Encounters WOP (including FEE ER visits) divided by the number of primary care encounters W

assigned primary care (or associate) provider plus the total VHA ER/Urgent Care/FEE ER Encounters (including FEE ER visits) W

primary care encounters WOP with a provider other than the patient’s PCP/AP. VA OIG Office of Healthcare Inspections 
CBOC and PCC Reviews at Minneapolis VA Health Care S

Data Definition.e Total Discharges Included in 2-day Contact Post Discharge Ratio: The total VHA and FEE Inpatient Discharges f

patients for the reporting timeframe. Discharges resulting in death and discharges where a patient is readmitted within 2 days of disc

this metric. 

VA OIG Office of Healthcare Inspections 
CBOC and PCC Reviews at Minneapolis VA Health Care System, Minneapolis, MN 

Appendix C 

VISN Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: August 26, 2014 

From: Director, VA Midwest Health Care Network (10N23) 

Subject: CBOC and PCC Reviews of the Minneapolis VA Health 

Care System, Minneapolis, MN 

To: Director, Denver Office of Healthcare Inspections (54DV) 

Director, Management Review Service (VHA 10AR MRS 

OIG CAP CBOC) 

I have reviewed the report of the Community Based Outpatient Clinic and 

Primary Care Clinic Reviews at the Minneapolis VA Health Care System 

conducted July 21-31, 2014, in addition to the MVAHCS response and 

action plans. I concur with the facility response and action plans. Thank 

you for the opportunity to review this report. 

 (original signed by:) 

JANET P. MURPHY, MBA 

Network Director 

VA OIG Office of Healthcare Inspections 15 
CBOC and PCC Reviews at Minneapolis VA Health Care System, Minneapolis, MN 

Appendix D 

Facility Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: August 21, 2014 

From: Director, Minneapolis VA Health Care System (618/00) 

Subject: CBOC and PCC Reviews of the Minneapolis VA Health 

Care System, Minneapolis, MN 

To: Director, VA Midwest Health Care Network (10N23) 

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

recommendations from the Community Based Outpatient Clinic and 

Primary Care Clinic Reviews at the Minneapolis VA Health Care 

System conducted July 21-31, 2014. I have reviewed the report and I 

concur with the recommendations and the action plans. 

2. If you have any questions please feel free to contact me at (612) 725-

2101. 

(original signed by:) 

Patrick J. Kelly, FACHE 

Director, Minneapolis VA Health Care System 

VA OIG Office of Healthcare Inspections 16 
CBOC and PCC Reviews at Minneapolis VA Health Care System, Minneapolis, MN 

Comments to OIG’s Report 

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

in the OIG report: 

OIG Recommendations 

Recommendation 1. We recommended that CBOC/Primary Care Clinic staff provide 

education and counseling for patients with positive alcohol screens and drinking alcohol 

above National Institute on Alcohol Abuse and Alcoholism limits. 

Concur 

Target date for completion: March 31, 2015 

Facility response: Clinical staff of the CBOC/Primary Care Clinics will receive education 

about providing education and counseling for patients with positive alcohol screens. 

Compliance with documentation of education and counseling provided to Veterans will 

be monitored through clinical reminder data and External Peer Review Program data, 

and will be reported to the Quality Management Council. 

Recommendation 2. We recommended that CBOC/Primary Care Clinic staff 

consistently document the offer of further treatment to patients diagnosed with alcohol 

dependence. 

Concur 

Target date for completion: March 31, 2015 

Facility response: Clinical staff of the CBOC/Primary Care Clinics will receive education 

about documenting the offer of further treatment to patients diagnosed with alcohol 

dependence. Data will be monitored monthly of the percent of patients with a positive 

screen for whom there was documentation that an offer of further treatment was made, 

and will be reported to the Quality Management Council. 

Recommendation 3. We recommended that managers ensure that patients with 

excessive persistent alcohol use receive brief treatment or are evaluated by a specialty 

provider within 2 weeks of the screening. 

Concur 

Target date for completion: March 31, 2015 

Facility response: Clinical staff of the CBOC/Primary Care Clinics and Mental Health 

providers will receive education about providing brief treatment or evaluation by a 

specialty provider within 2 weeks of screening when the screening identifies that the 

patient has excessive persistent alcohol use. The percent of patients for whom there 

VA OIG Office of Healthcare Inspections 17 
 

CBOC and PCC Reviews at Minneapolis VA Health Care System, Minneapolis, MN 

was documentation that brief treatment or an evaluation by a specialty provider was 

completed when required will be monitored and reported to the Quality Management 

Council. 

Recommendation 4. We recommended that CBOC/Primary Care Clinic Registered 

Nurse Care Managers receive motivational interviewing and health coaching training 

within 12 months of appointment to Patient Aligned Care Teams. 

Concur 

Target date for completion: March 31, 2015 

Facility response: All RN Case Managers will receive motivational interviewing and 

health coaching training within a year of assignment to a Patient Aligned Care Team 

(PACT), and new staff will receive this training as part of New Employee Orientation. 

Monthly education data will be reported to Chiefs of the Primary Care Clinics, RN Clinic 

Directors, and Primary Care Patient Service Line leaders, with the goal of maintaining 

compliance with training requirements as new staff are added to PACT teams. 

Recommendation 5. We recommended that staff document that medication 

reconciliation was completed at each episode of care where the newly prescribed 

fluoroquinolone was administered, prescribed, or modified. 

Concur 

Target date for completion: December 31, 2014 

Facility response: Staff will document medication reconciliation at each episode of care 

when prescribing, administering or modifying fluoroquinolone. Use of a Medication 

Reconciliation template to include this documentation has been reinforced via an 

education memorandum from the Chief of Staff on July 11, 2014. Audits of the medical 

record outpatient visits will be conducted to ensure that medication reconciliation is 

documented. 

Recommendation 6. We recommended that staff provide medication 

counseling/education as required. 

Concur 

Target date for completion: December 31, 2014 

Facility response: Physicians and pharmacists will provide medication 

counseling/education when new medications are prescribed or when medication orders 

are changed. Staff were educated in a memorandum from the Chief of Staff on July 11, 

2014. A medication education template was revised on July 15, 2014 to ensure that 

proper medication counseling/education was completed and documented in the medical 

record. Audits of the medical record outpatient visits will be conducted to ensure that 

medication education is documented by physicians and pharmacists when required. 

VA OIG Office of Healthcare Inspections 18 
CBOC and PCC Reviews at Minneapolis VA Health Care System, Minneapolis, MN 

Recommendation 7. We recommended that clinical executive/primary care leaders 

ensure that CBOC/Primary Care Clinic Designated Women’s Health Providers maintain 

proficiency as required for the provision of women’s health care. 

Concur 

Target date for completion: December 31, 2014 

Facility response: A “Women’s Health Update” program was developed to ensure 

proficiency in providing women’s health care, and will be offered on September 24-25, 

2014 for all Designated Women’s Health Providers (DWHP) and primary care providers 

who are interested in being designated as Women’s Health Providers. Staff may submit 

documentation of an alternate training or experience in women’s health to meet the 

proficiency requirements. To maintain proficiency going forward, DWHP who do not 

have 10% female patients in their panels will be required to provide documentation on 

an annual basis of continuing education or experience. Compliance will be tracked by 

the Women Veterans Program Manager and reported annually to the Women Veterans 

Advisory Committee. 

Recommendation 8. We recommended that the chief of staff consistently ensure that 

all Designated Women’s Health Providers are designated with the women’s health 

indicator in the Primary Care Management Module. 

Concur 

Target date for completion: August 31, 2014 

Facility response: In May 2014, all providers were accurately entered in the Primary 

Care Management Module (PCMM) as Designated Women’s Health Providers (DWHP). 

Monthly reports will be submitted to the Women’s Health Medical Director and the Chief 

of Staff demonstrating that the PCMM is kept up to date as changes occur, with all 

DWHP’s correctly designated. 

VA OIG Office of Healthcare Inspections 19 
CBOC and PCC Reviews at Minneapolis VA Health Care System, Minneapolis, MN 

Appendix E 

OIG Contact and Staff Acknowledgments 

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

at (202) 461-4720. 

Onsite Virginia Solana, RN, MA 

Contributors 

Other 

Contributors 

Ann Ver Linden, RN, MBA, Team Leader 

Cheryl Walker, ARNP, MBA 

Lin Clegg, PhD 

Matt Frazier, MPH 

Jeff Joppie, BS 

Jennifer Reed, RN, MSHI 

Victor Rhee, MHS 

Patrick Smith, M. Stat 

Marilyn Stones, BS 

Mary Toy, RN, MSN 

Jarvis Yu, MS 

VA OIG Office of Healthcare Inspections 20 
CBOC and PCC Reviews at Minneapolis VA Health Care System, Minneapolis, MN 

Appendix F 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VA Midwest Health Care Network (10N23) 

Director, Minneapolis VA Health Care System (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: Tammy Baldwin, Al Franken, Ron Johnson, Amy Klobuchar 

U.S. House of Representatives: Michele Bachmann, Sean P. Duffy, Keith Ellison, 

John Kline, Betty McCollum, Rick Nolan, Erik Paulsen, Collin C. Peterson, 

Timothy J. Walz 

This report is available at www.va.gov/oig. 

VA OIG Office of Healthcare Inspections 21 
 

 

 

 

 

CBOC and PCC Reviews at Minneapolis VA Health Care System, Minneapolis, MN 

Appendix G 

Endnotes 

a

 References used for the EOC review included: 

	 US Access Board, Americans with Disabilities Act Accessibility Guidelines (ADAAG), September 2, 2002. 

	 US Department of Health and Human Services, Health Insurance Portability and Accountability Act, The 

Privacy Rule, August 14, 2002. 

	 US Department of Labor, Occupational Safety and Health Administration, Laws and Regulations. 

	 US Department of Labor, Occupational Safety and Health Administration, Guidelines for Preventing Workplace 

Violence, 2004. 

	 Joint Commission, Joint Commission Comprehensive Accreditation and Certification Manual, July 1, 2013. 

	 VA Directive 0324, Test, Training, Exercise, and Evaluation Program, April 5, 2012. 

	 VA Directive 0059, VA Chemicals Management and Pollution Prevention, May 25, 2012. 

	 VA Handbook 6500, Risk Management Framework for VA Information System, September 20, 2012. 

	 VHA Center for Engineering, Occupational Safety, and Health, Emergency Management Program Guidebook, 

March 2011. 

	 VHA Center for Engineering, Occupational Safety, and Health, Online National Fire Protection Association 

Codes, Standards, Handbooks, and Annotated Editions of Select Codes and Standards, July 9, 2013. 

	 VHA Deputy Under Secretary for Health for Operations and Management, Memorandum: Environmental 

Rounds, March 5, 2007. 

	 VHA Directive 2011-007, Required Hand Hygiene Practices, February 16, 2011. 

	 VHA Directive 2012-026, Sexual Assaults & Other Defined Public Safety Incidents in VHA Facilities, 

September 27, 2012. 

	 VHA Handbook 1006.1, Planning and Activating Community-Based Outpatient Clinics, May 19, 2004. 

	 VHA Handbook 1330.01, Health Care Services for Women Veterans, May 21, 2010. 

	 VHA Handbook 1850.05, Interior Design Operations and Signage, July 1, 2011. 

b

 References used for the AUD review included: 

	 National Center for Health Promotion and Disease Prevention (NCP), Veteran Health Education and Information 

(NVEI) Program, Patient Education: TEACH for Success. Retrieved from 

http://www.prevention.va.gov/Publications/Newsletters/2013/HealthPOWER_Prevention_News_Winter_2012_2 

013_FY12_TEACH_MI_Facilitator_Training.asp on January 17, 2014. 

	 VHA Handbook 1120.02, Health Promotion Disease Prevention (HPDP) Program, July 5, 2012. 

	 VHA Handbook 1160.01, Uniform Mental Health Services in VA Medical Centers and Clinics, 

September 11, 2008. c

 References used for the Medication Management review included: 

	 VHA Directive 2011-012, Medication Reconciliation, March 9, 2011. 

	 VHA Directive 2012-011, Primary Care Standards, April 11, 2012. 

	 VHA Handbook 1108.05, Outpatient Pharmacy Services, May 30, 2006. 

	 VHA Handbook 1108.07, Pharmacy General Requirements, April 17, 2008. 	 Joint Commission, Joint Commission Comprehensive Accreditation and Certification Manual, July 1, 2013. 

d

 References used for the DWHP review included: 

	 VHA Deputy Under Secretary for Health for Operations and Management, Memorandum: Health Care Services 

for Women Veterans, Veterans Health Administration (VHA) Handbook 1330.01; Women’s Health (WH) 

Primary Care Provider (PCP) Proficiency, July 8, 2013. 

	 VHA Handbook 1330.01 Health Care Services for Women Veterans, May 21, 2010. 

	 VHA Handbook 1100.19, Credentialing and Privileging, November 14, 2008. e

 Reference used for PACT Compass data graphs: 

	 Department of Veterans’ Affairs, Patient Aligned Care Teams Compass Data Definitions, August 29, 2013. 

VA OIG Office of Healthcare Inspections 22