Department of Veterans Affairs 

Office of Inspector General 

Healthcare Inspection 

Community Based Outpatient 

Clinic Reviews 

Macon and Albany, GA 

Beaver Dam, WI and Rockford, IL 

Sioux City, IA and Aberdeen, SD 

Waterloo, IA and Galesburg, IL 

Report No. 09-01446-37 December 2, 2009

VA Office of Inspector General 

Washington, DC 20420 
 

 

 

To Report Suspected Wrongdoing in VA Programs and Operations 

Telephone: 1-800-488-8244 between 8:30AM and 4PM Eastern Time,

 Monday through Friday, excluding Federal holidays

 E-Mail: vaoighotline@va.gov 
CBOC Reviews: Macon, Albany, Beaver Dam, Rockford, Sioux City, Aberdeen, Waterloo, and Galesburg 

Contents 

Page 

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

I. Introduction ..................................................................................................... 1 

Purpose ........................................................................................................................... 1

Background .................................................................................................................... 1

Scope and Methodology ................................................................................................ 1

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

III. Overview of Review Topics ............................................................................ 5 

IV. Results and Recommendations ..................................................................... 6 

A. VISN 7, Carl Vinson (Dublin) VAMC – Macon and Albany ................................. 6 

B. VISN 12, William S. Middleton Memorial Veterans Hospital (Madison) – Beaver 

Dam and Rockford ....................................................................................................... 15 

C. VISN 23, Sioux Falls VAMC – Sioux City and Aberdeen .................................... 19 

D. VISN 23, Iowa City VAMC – Waterloo and Galesburg ....................................... 22 

Appendixes

A. VISN 7 Director Comments ................................................................................... 28 

B. Dublin VAMC Director Comments ....................................................................... 29 

C. VISN 12 Director Comments ................................................................................. 33 

D. Madison Director Comments ................................................................................. 34 

E. VISN 23 Director Comments ................................................................................. 37 

F. Sioux Falls VAMC Director Comments ................................................................. 38 

G. Iowa City VAMC Director Comments .................................................................. 41 

H. CBOC Characteristics ............................................................................................ 44 

I. Quality of Care Measures – Macon and Albany ..................................................... 46 

J. Quality of Care Measures – Beaver Dam and Rockford ......................................... 48 

K. Quality of Care Measures – Sioux City and Aberdeen .......................................... 50 

L. Quality of Care Measures – Waterloo and Galesburg ............................................ 52 

M. OIG Contact and Staff Acknowledgments ............................................................ 54

N. Report Distribution................................................................................................. 55 

VA Office of Inspector General 
CBOC Reviews: Macon, Albany, Beaver Dam, Rockford, Sioux City, Aberdeen, Waterloo, and Galesburg 

Executive Summary 

Introduction

As requested in House Report 110-775, to accompany H.R. 6599, Military Construction, 

Veterans Affairs, and Related Agencies Appropriation Bill, fiscal year (FY) 2009, the 

VA Office of Inspector General (OIG) is beginning a systematic review of Veterans 

Health Administration (VHA) community based outpatient clinics (CBOCs). 

The VA OIG, Office of Healthcare Inspections conducted a review of eight CBOCs 

during the week of September 14–18, 2009. The CBOCs reviewed in Veterans 

Integrated Service Network (VISN) 7 were Macon and Albany, GA; in VISN 12, Beaver 

Dam, WI and Rockford, IL; and, in VISN 23, Sioux City, IA and Aberdeen, SD; and 

Waterloo, IA and Galesburg, IL. The parent facilities of these CBOCs are Carl Vinson 

(Dublin) VA Medical Center (VAMC), William S. Middleton Memorial Veterans 

Hospital (Madison), Sioux Falls VAMC, and Iowa City VAMC, respectively. The 

purpose of the review was to assess whether CBOCs are operated in a manner that 

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

Results and Recommendations 

The CBOC review covered five topics. In our review, we noted several opportunities for 

improvement and made recommendations to address all of these issues. The Directors, 

VISN 7, 12 and 23, in conjunction with the respective facility manager, should take 

appropriate actions on the following recommendations: 

• Require that contract requirements for physicians are met or aligned with VHA 

requirements. 

• Ensure that contract providers are privileged according to policy. 

• Review privileges that have been granted to clinical staff and grant privileges that 

are consistent with CBOC providers’ practices. 

• When reprivileging, compare practitioner data to aggregated data of those 

privileged practitioners who hold the same or comparable privileges. 

• Require that the Ongoing Professional Practice Evaluation (OPPE) plan, OPPE 

data, and the privileging process are managed in accordance with VHA 

requirements. 

• Ensure the panic alarm system is functional. 

• Conduct an information technology network security assessment and correct any 

vulnerability. 

VA Office of Inspector General i 
CBOC Reviews: Macon, Albany, Beaver Dam, Rockford, Sioux City, Aberdeen, Waterloo, and Galesburg 

VA Office of Inspector General ii 

• Improve access for disabled veterans. 

• Evaluate the effectiveness of the panic alarm system. 

• Require that staff are able to safely access the sharps containers. 

• Lock all computer stations when not in use. 

• Maintain personally identifiable information in a secure manner. 

• Develop a local policy for medical emergencies that reflects the current practice 

and capability of the CBOC. 

• Provide contract oversight and enforcement in accordance with the terms and 

conditions as stated in the contract. 

• Review key contractual provisions with the Contracting Officer’s Technical 

Representative (COTRs) and ensure the COTRs understand the terms of the 

contract and criteria. 

• Monitor the COTR’s oversight by evaluating the evidence that the COTR’s review 

and approval of contractor invoices is in compliance with terms of the contract. 

• Ensure that contractor performance measures are evaluated against the criteria 

established in the contract. 

• Receive contractor invoices in electronic format in addition to paper documents to 

facilitate invoice analysis. 

• Provide contractor with a current list of inactivated enrollees to prevent future 

overcharges on billings. 

Comments 

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

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

pages 28–43 for the full text of the Directors’ comments.) 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 
CBOC Reviews: Macon, Albany, Beaver Dam, Rockford, Sioux City, Aberdeen, Waterloo, and Galesburg 

VA Office of Inspector General 1 

Part I. Introduction 

Purpose 

As requested in House Report 110-775, to accompany H.R. 6599, Military Construction, 

Veterans Affairs, and Related Agencies Appropriation Bill, fiscal year (FY) 2009, 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). 

Background 

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 to 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. For 

additional background information, see the Informational Report for the Community 

Based Outpatient Clinic Cyclical Reports, 08-00623-169, issued July 16, 2009. 

Scope and Methodology 

Objectives. The purpose of this review is to assess whether CBOCs are operated in a 

manner that provides veterans with consistent, safe, high-quality health care in 

accordance with VA policies and procedures. The objectives of the review are to: 

• Determine whether CBOC performance measure scores are comparable to the 

parent VA medical center (VAMC) outpatient clinics. 

• Determine whether CBOC providers are appropriately credentialed and privileged 

in accordance to VHA Handbook 1100.19.1

• Determine whether CBOCs maintain the same standard of care as their parent 

facility to address the Mental Health (MH) needs of Operation Enduring 

Freedom/Operation Iraqi Freedom (OEF/OIF) era veterans. 

 

1

 VHA Handbook 1100.19, Credentialing and Privileging, November 14, 2008. 
CBOC Reviews: Macon, Albany, Beaver Dam, Rockford, Sioux City, Aberdeen, Waterloo, and Galesburg 

VA Office of Inspector General 2 

• Determine whether CBOCs are in compliance with standards of operations 

according to VHA Handbook 1006.12

 in the areas of environmental safety and 

emergency planning. 

• Determine the effect of CBOCs on veteran perception of care. 

• Determine whether CBOC contracts are administered in accordance with contract 

terms and conditions. 

Scope. We reviewed CBOC policies, performance documents, provider credentialing 

and privileging (C&P) files, and nurses’ training records. For each CBOC, random 

samples of 50 patients with a diagnosis of diabetes mellitus (DM), 50 patients with a 

diagnosis of ischemic vascular disease, and 30 patients with a service separation date 

after September 11, 2001, without a diagnosis of post-traumatic stress disorder (PTSD), 

were selected, unless fewer patients were available. We reviewed the medical records of 

these selected patients to determine compliance with VHA performance measures. 

We conducted environment of care (EOC) inspections to determine the CBOCs’ 

cleanliness and conditions of the patient care areas; conditions of equipment, adherence 

to clinical standards for infection control and patient safety; and compliance with patient 

data security requirements. 

We also reviewed FY 2008 Survey of Healthcare Experiences of Patients (SHEP) data to 

determine patients’ perceptions of the care they received at the CBOCs. 

We conducted the inspection in accordance with Quality Standards for Inspections 

published by the President’s Council on Integrity and Efficiency.

In this report, we make recommendations for improvement. 

 

2

 VHA Handbook 1006.1, Planning and Activating Community-Based Outpatient Clinics, May 19, 2004. 
CBOC Reviews: Macon, Albany, Beaver Dam, Rockford, Sioux City, Aberdeen, Waterloo, and Galesburg 

Part II. CBOC Characteristics 

Veterans Integrated Service Network (VISN) 7 has 10 VHA hospitals and 28 CBOCs, 

VISN 12 has 7 VHA hospitals and 32 CBOCs, and VISN 23 has 10 hospitals and 

49 CBOCs. As part of our review, we inspected 8 CBOCs (6 VA staffed and 2 with 

contracted staff). The CBOCs reviewed in VISN 7 were Macon and Albany, GA; in 

VISN 12, Beaver Dam, WI and Rockford, IL; and, in VISN 23, Sioux City, IA and 

Aberdeen, SD; and Waterloo, IA and Galesburg, IL. The parent facilities of these 

CBOCs are Carl Vinson (Dublin) VAMC, William S. Middleton Memorial Veterans 

Hospital (Madison), Sioux Falls VAMC, and Iowa City VAMC, respectively. 

We formulated a list of CBOC characteristics and developed an information request for 

data collection. The characteristics included identifiers and descriptive information for 

the CBOC evaluation. 

In FY 2008, the average number of unique patients seen at the 6 VA-staffed CBOCs was 

3,885 (range 1,824 to 7,290) and at the contract CBOCs was 5,519 (range 4,738 to 

6,299). Figure 1 shows characteristics of the 8 CBOCs we reviewed to include type of 

CBOC, rurality, number of clinical full-time equivalent employees (FTE), number of 

unique veterans enrolled in the CBOC, and number of veteran visits. 

VISN 

Number 

CBOC 

 Name 

Parent 

 VAMC 

CBOC 

Type 

Urban/ 

Rural 

Number of 

Clinical Providers 

(FTE) 

Uniques Visits 

7 Macon, GA Dublin, GA Contract Rural 7.75 6,299 17,502 

7 Albany, GA Dublin, GA Contract Rural 6.0 4,738 17,116 

12 Beaver Dam, WI Madison, WI VA Staffed Rural 1.8 1,824 4,622 

12 Rockford, IL Madison, WI VA Staffed Urban 7.5 7,290 30,469 

23 Sioux City, IA Sioux Falls, SD VA Staffed Rural 3.95 3,586 14,621 

23 Aberdeen, SD Sioux Falls, SD VA Staffed Rural 2.08 2,506 12,931 

23 Waterloo, IA Iowa City, IA VA Staffed Urban 3.95 4,893 15,027 

23 Galesburg, IL Iowa City, IA VA Staffed Urban 3.00 3,209 10,506 

Figure 1 - CBOC Characteristics, FY 2008 

Four of the eight CBOCs provide specialty care services (Macon, Rockford, Galesburg, 

and Waterloo), while the other four CBOCs refer patients to the parent facility. Macon 

provides podiatry; Rockford provides gastrointestinal, physical therapy, podiatry, and 

neurology/traumatic brain injury (TBI); and Galesburg and Waterloo provide services in 

diabetes self-management and an outpatient substance abuse treatment program. 

All eight CBOCs provide electrocardiograms (EKGs), and six have laboratory services 

onsite. Two of the eight are able to provide basic blood tests onsite (Galesburg and 

Waterloo). Veterans have access to social services at three CBOCs. Three CBOCs 

provide onsite dietary services. Three of the eight CBOCs we reviewed provide telemedicine. The CBOC at Rockford has an onsite pharmacy. 

All eight CBOCs provide MH services onsite. The type of clinicians who provide MH 

services varied among the CBOCs to include primary care physicians, psychologists, 

VA Office of Inspector General 3 
CBOC Reviews: Macon, Albany, Beaver Dam, Rockford, Sioux City, Aberdeen, Waterloo, and Galesburg 

psychiatrists, nurse practitioners, and social workers. Tele-mental health is available at 

six CBOCs. Seven CBOCs report that MH services are provided 5 days a week, and the 

other CBOC provides MH services 1.5 days per week. Additional CBOC characteristics 

are listed in Appendix H.

VA Office of Inspector General 4 
CBOC Reviews: Macon, Albany, Beaver Dam, Rockford, Sioux City, Aberdeen, Waterloo, and Galesburg 

Part III. Overview of Review Topics 

The review topics discussed in this report include: 

• Quality of Care Measures. 

• C&P. 

• EOC and Emergency Management. 

• Patient Satisfaction. 

• CBOC Contracts. 

The criteria used for these reviews are discussed in detail in the Informational Report for 

the Community Based Outpatient Cyclical Reports, 08-00623-169, issued July 16, 2009. 

We evaluated the quality of care measures by reviewing 50 patients with a diagnosis of 

DM, 50 patients with a diagnosis of ischemic vascular disease, and 30 patients with a 

service separation date after September 11, 2001 (without a diagnosis of PTSD), unless 

fewer patients were available. We reviewed the medical records of these selected 

patients to determine compliance with first (1st) quarter (Qtr), FY 2009 VHA 

performance measures. 

We conducted an overall review to assess whether the medical center’s C&P process 

complied with VHA Handbook 1100.19. We reviewed CBOC providers’ C&P files and 

nursing staff personnel folders. In addition, we reviewed the background checks for the 

CBOC clinical staff. 

We conducted EOC inspections at each CBOC, evaluating cleanliness, adherence to 

clinical standards for infection control and patient safety, and compliance with patient 

data security requirements. We evaluated whether the CBOCs had a local 

policy/guideline defining how health emergencies, including MH emergencies, are 

handled. 

We reviewed and discussed recent SHEP data (FY 2008) with the senior leaders. If the 

SHEP scores did not meet VHA’s target goal of 77, we interviewed the senior managers 

to assess whether they had analyzed the data and taken action to improve their scores. 

We evaluated whether the two CBOC contracts (Macon and Albany) provided guidelines 

that the contractor needed to follow in order to address quality of care issues. We also 

verified that the number of enrollees or visits reported was supported by collaborating 

documentation. 

VA Office of Inspector General 5 
CBOC Reviews: Macon, Albany, Beaver Dam, Rockford, Sioux City, Aberdeen, Waterloo, and Galesburg 

VA Office of Inspector General 6 

Part IV. Results and Recommendations 

A. VISN 7, Dublin VAMC – Macon and Albany 

Quality of Care Measures 

The Macon CBOC quality measures scores equaled or exceeded the parent facility 

scores. The Albany CBOC equaled or exceeded the parent facility for all measures 

except hyperlipidemia screening, and DM retinal eye exam and lipid profile. (See 

Appendix I.) 

Credentialing and Privileging 

We reviewed the C&P files of five providers and the personnel folders of three nurses at 

both the Macon and Albany CBOCs. All providers possess a full, active, current, and 

unrestricted license. All nurses’ license and education requirements were verified and 

documented. However, we identified the following areas that needed improvement: 

Credentialing

Contract Providers’ Credentialing Requirement 

The Macon and Albany CBOC contracts mandate that all physician providers be board 

certified in either Internal Medicine or Family Practice Medicine. Review of the Macon 

CBOC physicians’ credentials revealed one physician was not board certified. 

Furthermore, the contract specified that practitioners under contract for both CBOCs will 

be certified in advanced cardiac life support (ACLS) certification. After review of the 

training records, we found that only two providers at each CBOC were ACLS certified. 

However, since neither CBOC had ACLS equipment or medications, the ACLS 

certification was beyond the scope of services provided at the CBOCs. 

Declaration of Health

The medical center obtained the providers’ health declarations during the initial and 

reappraisal process, as required by VHA Handbook 1100.19, but failed to scan the health 

declarations for all providers into the VetPro system3

 as required. Failure to scan these 

documents into the VetPro system has the potential of decreasing the efficiency and 

accuracy of the credentialing process. Because hard copies of the health declarations 

were available for review during the reappraisal process and senior managers have agreed 

to scan the declarations into the VetPro system, we did not make a recommendation. 

 

3

 VetPro is a Web-based physician credentialing system. Its use allows for accurate and complete credentials to be 

obtained once, electronically banked, and retrieved for review and updating in a secure Web-based environment. 
CBOC Reviews: Macon, Albany, Beaver Dam, Rockford, Sioux City, Aberdeen, Waterloo, and Galesburg 

VA Office of Inspector General 7 

Privileging

Contract Providers’ Privilege Period 

Both the Macon and Albany CBOCs contract providers were privileged for a 2-year 

period even though the contract was for 1 year. VHA Handbook 1100.19 states that 

clinical privileges granted to contractors may not extend beyond the contract period. 

Clinical Privileges 

Providers at the Macon and Albany CBOCs were granted privileges for practices not 

performed at the CBOC. Examples included: admitting privileges, suturing, and 

interpreting Holter Monitor4

 printouts and EKG final interpretations. The medical center 

managers stated these privileges should not have been granted to the CBOC providers. 

According to VHA Handbook 1100.19, only privileges for procedures actually provided 

by the VA facility may be granted to a practitioner. 

Recommendation 1. We recommended that the VISN 7 Director ensure that the Dublin 

VAMC Director requires that the contract requirements for physicians are met or aligned 

with VHA requirements at the Macon and Albany CBOCs. 

The VISN and VAMC Directors concurred with our finding and recommendation. The 

facility has submitted a request for modification to the contract officer to change the 

verbiage of the requirements for physicians to be board certified or board eligible. The 

improvement plans are acceptable, and we will follow up on the planned actions until 

they are completed. 

Recommendation 2. We recommended that the VISN 7 Director ensure that the Dublin 

VAMC Director requires that contract providers at the Macon and Albany CBOCs are 

privileged according to VHA policy. 

The VISN and VAMC Directors concurred with our finding and recommendation. The 

Medical Center Chief of Staff has changed the privileging policy and developed a 

different privileging form for CBOC providers. The improvement plans are acceptable, 

and we will follow up on the planned actions until they are completed. 

Recommendation 3. We recommended that the VISN 7 Director ensure that the Dublin 

VAMC Director requires that clinical managers review the privileges that have been 

granted to clinical staff and grant privileges that are consistent with providers’ practices 

at the Macon and Albany CBOCs. 

The VISN and VAMC Directors concurred with our finding and recommendation. The 

Medical Center Chief of Staff has changed the privileging policy and developed a 

 

4

 A portable continuous electrocardiographic recorder. 
CBOC Reviews: Macon, Albany, Beaver Dam, Rockford, Sioux City, Aberdeen, Waterloo, and Galesburg 

different privileging form for CBOC providers. The improvement plans are acceptable, 

and we will follow up on the planned actions until they are completed. 

Environment and Emergency Management 

Environment of Care

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

control, and general maintenance. Both CBOCs’ internal EOCs were clean and well 

maintained. However, we identified the following area that needed improvement: 

Panic Alarms 

The Macon and Albany CBOCs provide MH services, and each had a panic alarm system 

in place for emergencies. However, we tested the system at the Albany CBOC and found 

that it was not functional during our site visit. The system at the Macon CBOC was also 

tested, and we found it to be functional. 

Recommendation 4. We recommended that the VISN 7 Director ensure that the Dublin 

VAMC Director requires a functional panic alarm system for the Albany CBOC. 

The VISN and VAMC Directors concurred with our finding and recommendation. A 

request has been submitted to remove the inoperable panic alarm system, and key staff at 

the Albany CBOC are wearing alert monitors. The improvement plans are acceptable, 

and we will follow up on the planned actions until they are completed. 

Emergency Management

VHA Handbook 1006.1 requires each CBOC have a local policy or standard operating 

procedure (SOP) defining how medical and MH emergencies are handled. Our 

interviews revealed staff at each facility articulated responses that accurately reflected the 

local policy. 

Patient Satisfaction 

SHEP results for FY 2008 are displayed in Figures 2 and 3. 

VA Office of Inspector General 8 
CBOC Reviews: Macon, Albany, Beaver Dam, Rockford, Sioux City, Aberdeen, Waterloo, and Galesburg 

Trip Pak Report - STA5 Level 

Patient Perceptions of Care 

2008 SHEP Performance Measures 

YTD Through September 2008 

Performance 

Measure (SHEP 

question #) 

Station 

Number 

Facility 

Name 

Data 

Type 

FY08 

Qtr 4 

FY08 

Qtr 3 

FY08 

Qtr 2 

VISN 

FY08, 

Qtr 4 

National 

FY08, 

Qtr 4 

(Q56) - Outpatients 

(percent Very 

Good, Excellent) 

557 Dublin Mean 

Score 

82.2 75 49.1 75 78.5

N= 50 60 47 2,457 54,400

557GA Macon 54.5 57.6 54.4 

 N= 67 75 79 

557GB Albany 68.9 72 78.4 

N= 47 66 71 

Figure 2. Outpatient Overall Quality 

The Albany CBOC scored below the VHA target score of 77 in the 3rd and 4th Qtrs, 

FY 2008 for “overall quality,” while the Macon CBOC scored below for all quarters. 

Managers at the Macon CBOC anticipated and addressed a decline in scores during the 

contract renewal process by (1) increasing time the provider spends with each patient, 

(2) utilizing the nursing clinic for walk-in and/or overflow patients, (3) addressing access 

to care by increasing the number of staff to answer the telephones, and (4) extending the 

clinic hours. 

Managers at the Albany CBOC also anticipated a decline in scores during the contract 

renewal process, which included relocation of the clinic. The following steps were taken 

to ensure continuity of care to the veterans: (1) provided written notification to all 

patients regarding the change in clinic location, (2) improved the telephone system to 

ensure all calls were answered promptly, (3) increased time the provider spends with each 

patient, (4) conducted rounds in the waiting rooms to assess patients’ needs and concerns, 

and (5) performed exit interviews with all patients. 

VA Office of Inspector General 9 
CBOC Reviews: Macon, Albany, Beaver Dam, Rockford, Sioux City, Aberdeen, Waterloo, and Galesburg 

Trip Pak Report - STA5 Level 

Patient Perceptions of Care 

2008 SHEP Performance Measures 

YTD Through September 2008 

Performance 

Measure (SHEP 

question #) 

Station 

Number 

Facility 

Name 

Data 

Type 

FY08 

Qtr 4 

FY08 

Qtr 3 

FY08 

Qtr 2 

VISN 

FY08, 

Qtr 4 

National 

FY08, 

Qtr 4 

(Q6) - (percent 

less than/equal to 

20 minutes) 

557 Dublin Mean 

Score 

51.9 55.8 52.4 72.7 77.3 

 N= 51 59 47 2,464 55,407 

557GA Macon 79.5 82.2 72.5 

 N= 68 73 75 

557GB Albany 81.6 83 88.4 

N= 51 70 73 

Figure 3. Provider Wait Times 

The parent facility failed to meet the VHA target score of 77 in FY 2008 for the 

“provider wait times”; however, both CBOCs met the VHA goal with the exception of 

Macon in the 2nd Qtr. 

CBOC Contract 

Macon CBOC 

The contract for the Macon CBOC is administered through the Dublin VAMC for 

delivery and management of primary and preventative medical care and continuity of 

care for all eligible veterans in VISN 7. Contracted services with Sterling Medical 

Associates, Inc. (Sterling) began on May 1, 2008, with option years extending through 

April 30, 2013. The contract terms state that the CBOC will have (1) a Georgia-licensed 

physician to serve as medical director and (2) other primary care providers to include 

Physician Assistants (PAs) and nurse practitioners. There were 7.75 FTE primary care 

providers for the 1st Qtr, FY 2009. The contractor was compensated by the number of 

enrollees at a monthly capitated rate per enrollee. The CBOC had 6,299 unique primary 

medical care enrollees with 17,502 visits as reported on the FY 2008 CBOC 

Characteristics report (see Figure 1). 

We reviewed the contract to determine the contract type, the services provided, the 

invoices submitted, and supporting information. We also performed inquiries of key 

Dublin VAMC and contractor personnel. Our review focused on documents and records 

for the 1st Qtr, FY 2009. We reviewed the methodology for tracking and reporting the 

number of enrollees in compliance with the terms of the contract. We reviewed 

capitation rates for compliance with the contract; form and substance of the contract 

invoices for ease of data analysis by the Contracting Officer’s Technical Representative 

(COTR); and duplicate, missing, or incomplete social security numbers (SSNs) on the 

invoices. 

VA Office of Inspector General 10 
CBOC Reviews: Macon, Albany, Beaver Dam, Rockford, Sioux City, Aberdeen, Waterloo, and Galesburg 

VA Office of Inspector General 11 

We noted the following regarding contract administration and oversight: 

A. The initial enrollee list provided to Sterling was not verified to include only active 

enrollees who had received services in the last 13 months. We inquired of the 

former COTR regarding the list of enrollees provided to Sterling and were informed 

that the list had not been reviewed to inactivate ineligible enrollees. 

B. We noted that 951 out of 6,839 (14 percent) reported on the December 2008 invoice 

should have been inactivated for billing purposes by the VAMC in accordance with 

the terms of the contract. 

The contract states under the provisions, (17) Enrollment for VA Benefits and 

Assignment of Patients, bullet (h) that, once assigned, the patient shall remain 

assigned until the VA inactivates the patient per inactivation criteria. In addition, 

provision (17)(i) bullet (3), states if the local facility has determined that an assigned 

patient should be seen annually; and, if the assigned patient has not been seen within 

the previous 13 months, the patient shall be inactivated at the CBOC. No 

compensation shall be provided for inactivated patients. 

Analytical tests were performed to determine compliance with the 13-month 

provision regarding billing of enrollees based upon services received at the clinic. 

We noted the following: 

• The list of 6,839 enrollees billed on the December 2008 invoice was 

compared to dates of services rendered as reported in the Veterans Health 

Information Systems and Technology Architecture (VistA) system. 

• The tests resulted in identifying enrollees billed to the VA who had not 

received any services within the prior 13 months at the CBOC for the period 

December 1, 2007, through December 31, 2008. This resulted in an 

overpayment to Sterling of approximately $22,300 for December 2008. 

However, since no enrollees were inactivated by the VAMC from January 

through June 2009, the VAMC may have made additional overpayments of 

approximately $133,750. 

• There were 388 enrollees billed to the VA who had not received any services 

within the prior 26 months at the CBOC for the period October 1, 2006, 

through December 31, 2008. 

C. The current COTR informed us that invoices for the period February through June 

2009 were approved for payment without reviewing any supporting details of 

enrollees. The supporting details for these invoices were later located in the former 

COTR’s office. 

D. We noted nine duplicate names on the December 2008 invoice. The SSNs 

correlating to the duplicate names were one digit off. 

E. We noted that the contract provisions regarding “negative incentives” were not 

being evaluated by the former or current COTR. The contract provisions in Section 
CBOC Reviews: Macon, Albany, Beaver Dam, Rockford, Sioux City, Aberdeen, Waterloo, and Galesburg 

VA Office of Inspector General 12 

III–Special Contract Requirements, (16) Performance Incentives, (b) Negative 

Incentive Options, provide financial penalties for the contractor if certain 

performance criteria are not met. If the VAMC is not assessing compliance with 

contract provisions on a timely basis, these provisions may not be enforceable. 

By not monitoring these provisions in the contract, VAMC is overpaying the contractor 

for these services. 

Albany CBOC 

The contract for the Albany CBOC is administered through the Dublin VAMC for 

delivery and management of primary and preventative medical care and continuity of 

care for all eligible veterans in VISN 7. Contracted services with Sterling began on 

October 1, 2008, with option years extending through March 31, 2013. The contract 

terms state that the CBOC will have (1) a Georgia-licensed physician to serve as medical 

director and (2) other primary care providers to include PAs and nurse practitioners. 

There were 6.0 FTE primary care providers for the 1st Qtr, FY 2009. The contractor was 

compensated by the number of enrollees at a monthly capitated rate per enrollee. The 

CBOC had 4,738 unique primary medical care enrollees with 17,116 visits as reported on 

the FY 2008 CBOC Characteristics report (see Figure 1). 

We reviewed the contract to determine the contract type, the services provided, the 

invoices submitted, and supporting information. We also performed inquiries of key 

Dublin VAMC and contractor personnel. Our review focused on documents and records 

for the 1st Qtr, FY 2009. We reviewed the methodology for tracking and reporting the 

number of enrollees in compliance with the terms of the contract. We reviewed 

capitation rates for compliance with the contract; form and substance of the contract 

invoices for ease of data analysis by the COTR; and duplicate, missing, or incomplete 

SSNs on the invoices. 

We noted the following regarding contract administration and oversight: 

A. The initial enrollee list provided to Sterling was not verified to include only active 

enrollees who had received services in the last 13 months. We inquired of the 

former COTR regarding the list of enrollees provided to Sterling and were informed 

that the list had not been reviewed to inactivate ineligible enrollees. We noted that 

709 out of 5,280 (13 percent) reported on the December 2008 invoice should have 

been inactivated for billing purposes by the VAMC in accordance with the terms of 

the contract. 

B. The contract states under the provisions, (17) Enrollment for VA Benefits and 

Assignment of Patients, bullet (h) that, once assigned, the patient shall remain 

assigned until the VA inactivates the patient per inactivation criteria. In addition, 

provision (17)(i) bullet (3), states if the local facility has determined that an assigned 

patient should be seen annually; and, if the assigned patient has not been seen within 
CBOC Reviews: Macon, Albany, Beaver Dam, Rockford, Sioux City, Aberdeen, Waterloo, and Galesburg 

VA Office of Inspector General 13 

the previous 13 months, the patient shall be inactivated at the CBOC. No 

compensation shall be provided for inactivated patients. 

Analytical tests were performed to determine compliance with the 13-month 

provision regarding billing of enrollees based upon services received at the clinic. 

We noted the following: 

• The list of 5,280 enrollees billed on the December 2008 invoice was 

compared to dates of services rendered as reported in the VistA system. 

• The tests resulted in identifying enrollees billed to the VA who had not 

received any services within the prior 13 months at the CBOC for the period 

December 1, 2007, through December 31, 2008. This resulted in an 

overpayment to Sterling of approximately $17,250 for December 2008. 

However, since no enrollees were inactivated by the VAMC from January 

through June 2009, the VAMC may have made additional overpayments of 

approximately $103,000. 

• There were 238 enrollees billed to the VA who had not received any services 

within the prior 26 months at the CBOC for the period October 1, 2006, 

through December 31, 2008. 

C. The current COTR informed us that invoices for the period February through June 

2009 were approved for payment without reviewing any supporting detail of 

enrollees. The supporting detail for these invoices was later located in the former 

COTR’s office. 

D. We noted eight duplicate names on the December 2008 invoice. The SSNs 

correlating to the duplicate names were one digit off. 

E. We noted that the contract provisions regarding “negative incentives” were not 

being evaluated by the former or current COTR. The contract provisions in Section 

III–Special Contract Requirements, (16) Performance Incentives, (b) Negative 

Incentive Options, provide financial penalties for the contractor if certain 

performance criteria are not met. If the VAMC is not assessing compliance with 

contract provisions on a timely basis, these provisions may not be enforceable. 

By not monitoring these provisions in the contract, VAMC is overpaying the contractor 

for these services. 

Recommendation 5. We recommended that the VISN 7 Director ensure that the Dublin 

VAMC Director provides contract oversight and enforcement in accordance with the 

terms and conditions as stated in the contract for the Macon and Albany CBOCs. 

Specifically, we recommended that the following measures be taken: 

A. Contracting officers should review key contractual provisions with the COTRs and 

ensure that the COTRs understand the terms of the contract and criteria on which 

contract performance is measured. 
CBOC Reviews: Macon, Albany, Beaver Dam, Rockford, Sioux City, Aberdeen, Waterloo, and Galesburg 

B. Contracting officers should monitor the COTR’s oversight by evaluating the 

evidence that the COTR’s review and approval of contractor invoices is in 

compliance with terms of the contract. COTRs should retain evidence of their 

review or be able to identify source documents/reports as evidence of their review. 

C. COTRs should ensure that contractor performance measures, including incentives 

and negative incentives, are evaluated against the criterion established in the 

contract. 

D. Contractor invoices should be received in electronic format (Microsoft Access or 

Excel) in addition to paper documents to facilitate invoice analysis. 

The VISN and VAMC Directors concurred with our finding and recommendation. The 

COTR is reviewing the provisions of the contract and developing new quality indicators 

that are easily quantifiable. The improvement plans are acceptable, and we will follow 

up on the planned actions until they are completed. 

Recommendation 6. We recommended that the VISN 7 Director ensure that the Dublin 

VAMC Director provide Sterling with a current list of inactivated enrollees to prevent 

future overcharges on billings for the Macon and Albany CBOCs. 

The VISN and VAMC Directors concurred with our finding and recommendation. The 

COTR is revising the process of recognizing inactivated enrollees and alerting the 

contractor on a monthly basis prior to invoice completion. The improvement plans are 

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

VA Office of Inspector General 14 
CBOC Reviews: Macon, Albany, Beaver Dam, Rockford, Sioux City, Aberdeen, Waterloo, and Galesburg 

VA Office of Inspector General 15 

B. VISN 12, Madison VAMC – Beaver Dam and Rockford 

Quality of Care Measures 

The Beaver Dam CBOC quality measure scores equaled or exceeded the parent facility 

scores. The Rockford CBOC equaled or exceeded the parent facility scores in all 

measures except for the DM retinal eye exam. (See Appendix J.) 

Credentialing and Privileging 

We reviewed the C&P files of four providers and the personnel folders of three nurses at 

the Beaver Dam CBOC and five providers and four nurses at the Rockford CBOC. All 

providers possess a full, active, current, and unrestricted license and privileges were 

appropriate for services rendered. All nurses’ license and education requirements were 

verified and documented. In addition, all background checks were initiated or completed. 

Environment and Emergency Management 

Environment of Care

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

control, and general maintenance. Both CBOCs met most standards and the 

environments were generally clean and safe. However, we identified the following areas 

that needed improvement: 

Information Security 

To prevent the unauthorized access of VA computer systems, staff must lock computer 

terminals when not in attendance. During our tour of the Rockford CBOC, we noted one 

unsecured computer terminal in an unlocked patent examination room. We were able to 

access the user’s email account without their knowledge. 

Personally Identifiable Information

According to Health Insurance Portability and Accountability Act (HIPAA)5

 regulations, 

control of the environment includes control of confidential patient information. The 

Rockford CBOC utilized an unlocked staff break room for inter-office mail distribution. 

During our tour, we found a locked bag marked “confidential” in a box designated for 

inter-office mail distribution. We also noted documents in practitioners’ mail slots that 

contained patient personally identifiable information (PII). Staff were not in the 

immediate area to ensure this information was secure from unauthorized access. 

 

5 The Health Insurance Portability and Accountability Act of 1996 Privacy Rule protects the privacy of individually 

identifiable health information. 
CBOC Reviews: Macon, Albany, Beaver Dam, Rockford, Sioux City, Aberdeen, Waterloo, and Galesburg 

Panic Alarms 

The Rockford CBOC provides MH services in two buildings, which are separated by a 

parking lot. The main building was equipped with a panic alarm system to notify 911 

services of an emergency event at the facility; however, it was not equipped with an 

internal system to notify building occupants of the emergency. The second building, 

where the majority of MH services are provided, was not equipped with a panic alarm 

system. Interviews revealed the Madison VAMC had recently contracted to purchase a 

computer-based system, capable of transmitting emergency alerts internally and to 911 

services, for the VAMC and its CBOCs, with plans to install the panic alarm system on or 

before October 1, 2009. Because the Madison VAMC had contracted to implement an 

internal and external panic alarm system at both Rockford CBOC buildings prior to this 

review, we did not make a recommendation. 

Recommendation 7. We recommended that the VISN 12 Director ensure that the 

Madison VAMC Director requires all computer stations at the Rockford CBOC are 

locked when not in use. 

The VISN and VAMC Directors concurred with our finding and recommendation. The 

importance of privacy and security, specifically logging off computer terminals when 

staff walk away from their computers, was reiterated at a Rockford CBOC staff meeting. 

The facility implemented a national policy that mandates all medical center computers to 

comply with security standards. The improvement plans are acceptable, and we will 

follow up on the planned actions until they are completed. 

Recommendation 8. We recommended that the VISN 12 Director ensure that the 

Madison VAMC Director requires PII be maintained in a more secure manner at the 

Rockford CBOC. 

The VISN and VAMC Directors concurred with our finding and recommendation. Staff 

mailboxes remain in the staff break room; however, the room is now secured by a locked 

door. The importance of maintaining confidential information in a secured environment 

has been reiterated at weekly staff meetings. The improvement plans are acceptable, and 

we will follow up on the planned actions until they are completed. 

Emergency Management 

VHA Handbook 1006.1 requires each CBOC to have a local policy or SOP defining how 

medical and MH emergencies are handled. The Beaver Dam CBOC did not have a local 

policy or SOP to instruct staff in how they were to respond if a patient presented with 

severe hypoglycemia (low blood sugar). The staff stated they would refer to the Madison 

VAMC hypoglycemia protocol. The protocol directs staff to administer oral glucose 

followed by intravenous (IV) glucose if oral glucose is ineffective. The CBOC was not 

VA Office of Inspector General 16 
CBOC Reviews: Macon, Albany, Beaver Dam, Rockford, Sioux City, Aberdeen, Waterloo, and Galesburg 

equipped for staff to administer IV glucose; therefore, they would administer oral glucose 

and then call 911 if ineffective. 

Recommendation 9. We recommended that the VISN 12 Director ensure that the 

Madison VAMC Director requires that Beaver Dam CBOC develops a local policy for 

medical emergencies that reflects the current practice and capability of the CBOC. 

The VISN and VAMC Directors concurred with our finding and recommendation. The 

nursing “Protocol for Treatment of Hypoglycemia” will be modified to reflect a decision 

point for inpatient versus outpatient care. The improvement plans are acceptable, and we 

will follow up on the planned actions until they are completed. 

Patient Satisfaction 

SHEP results for FY 2008 are displayed in Figures 4 and 5. 

Trip Pak Report - STA5 Level 

Patient Perceptions of Care 

2008 SHEP Performance Measures 

YTD Through September 2008 

Performance 

Measure (SHEP 

question #) 

Station 

Number 

Facility Name Data 

Type 

FY08 

Qtr 4 

FY08 

Qtr 3 

FY08 

Qtr 2 

VISN 

FY08, 

Qtr 4 

National 

FY08, 

Qtr 4 

(Q56) - Outpatients 

(percent Very 

Good, Excellent) 

607 Madison Mean 

Score 

92 95.8 82.1 79.9 78.5

N= 66 79 81 2782 54,400

607GE Beaver Dam 83.8 90.3 88.8 

N= 86 90 92 

607HA Rockford 75.7 71.5 82.2 

N= 87 80 76 

Figure 4. Outpatient Overall Quality 

For “overall quality”, Beaver Dam equaled the medical center in the 

2nd Qtr and met VHA target score of 77 in all quarters. However, Beaver Dam scored 

below the parent facility’s SHEP scores in 3rd and 4th Qtrs, FY 2008. 

Rockford CBOC exceeded the parent facility for “overall quality” and met VHA target 

score of 77 in 2nd Qtr, FY 2008. However, Rockford CBOC scored below the parent 

facility’s SHEP and VHA target score of 77 in the 3rd and 4th Qtrs. We learned the CBOC 

had experienced a high turnover of staff during the 3rd and 4th Qtrs, which increased 

patients’ wait times. We interviewed staff and reviewed supporting documents and 

learned all FTE positions had been filled at Rockford’s CBOC prior to our site visit. 

VA Office of Inspector General 17 
CBOC Reviews: Macon, Albany, Beaver Dam, Rockford, Sioux City, Aberdeen, Waterloo, and Galesburg 

Trip Pak Report - STA5 Level 

Patient Perceptions of Care 

2008 SHEP Performance Measures 

YTD Through September 2008 

Performance 

Measure (SHEP 

question #) 

Station 

Number 

Facility Name Data 

Type 

FY08 

Qtr 4 

FY08 

Qtr 3 

FY08 

Qtr 2 

VISN 

FY08, 

Qtr 4 

National 

FY08, Qtr 4 

(Q6) - (percent 

less than/equal to 

20 minutes) 

607 Madison Mean 

Score 

72.3 90.2 85 76.5 77.3 

 N= 67 78 79 2,846 55,407 

607GE Beaver Dam 96.6 98.1 92.6 

N= 89 98 100 

607HA Rockford 86.2 85.6 90.4 

N= 85 78 74 

Figure 5. Provider Wait Times 

The Beaver Dam CBOC exceeded the parent facility’s “provider wait times” scores in 

FY 2008. The Rockford CBOC failed to meet the parent facility SHEP scores in the 

3rd Qtr, FY 2008. Both CBOCs met the VHA target score of 77 in all quarters. 

VA Office of Inspector General 18 
CBOC Reviews: Macon, Albany, Beaver Dam, Rockford, Sioux City, Aberdeen, Waterloo, and Galesburg 

C. VISN 23, Sioux Falls VAMC – Sioux City and Aberdeen 

Quality of Care Measures 

The Sioux City CBOC quality measure scores equaled or exceeded the parent facility 

scores. The Aberdeen CBOC equaled or exceeded the parent facility scores with the 

exception of DM retinal exam and lipid testing and PTSD screening. (See Appendix K.) 

Credentialing and Privileging 

We reviewed the C&P files of five providers and the personnel folders for four nurses at 

the Sioux City CBOC and four providers and four nurses at the Aberdeen CBOC. All 

providers possess a full, active, current, and unrestricted license. All nurses’ license and 

education requirements were verified and documented. However, we identified the 

following areas that needed improvement: 

Clinical Privileging 

The Professional Standards Board had granted providers clinical privileges for 

procedures that had not been performed at the Aberdeen CBOC within the past 

reprivileging cycle. For example, a PA was granted privileges to administer IV 

medications; however, IV medications were not administered at the CBOC. In addition, 

a physician was granted privileges to perform ACLS; however, the CBOC did not have 

ACLS medications or equipment and managers had indicated that the clinic was a 911 

facility. 

Additionally, according to VHA Handbook 1119: 

The reappraisal process needs to include consideration of such factors as 

the number of procedures performed or major diagnoses treated, rates of 

complications compared with those of others doing similar procedures, and 

adverse results indicating patterns or trends in a practitioner's clinical 

practice. Relevant practitioner-specific data needs to be compared to the 

aggregate data of those privileged practitioners that hold the same or 

comparable privileges. 

We found that the service chiefs collected practitioner-specific data on the major 

diagnoses treated at both CBOCs. However, this practitioner-specific data was not 

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

comparable privileges. 

Recommendation 10. We recommended that the VISN 23 Director ensure that the 

Sioux Falls VAMC Director requires that clinical managers grant privileges that are 

consistent with providers’ practices and with the clinical setting at the Aberdeen CBOC. 

VA Office of Inspector General 19 
CBOC Reviews: Macon, Albany, Beaver Dam, Rockford, Sioux City, Aberdeen, Waterloo, and Galesburg 

The VISN and VAMC Directors concurred with our finding and recommendation. The 

Credentialing Coordinator will request that all CBOC Medical Directors review the 

CBOC provider privileges based on the clinical setting. The recommended changes will 

be submitted to the Professional Standards Board (PSB). The improvement plans are 

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

Recommendation 11. We recommended that the VISN 23 Director ensure that the 

Sioux Falls VAMC Director requires that when reprivileging, practitioner data be 

compared to aggregate data of those privileged practitioners who hold the same or 

comparable privileges at the Sioux City and Aberdeen CBOCs. 

The VISN and VAMC Directors concurred with our finding and recommendation. The 

medical center has developed a process to ensure that when reprivileging, practitioner 

data will be compared to aggregated data of those privileged practitioners who hold the 

same or comparable privileges. The improvement plans are acceptable, and we will 

follow up on the planned actions until they are completed. 

Environment and Emergency Management 

Environment of Care

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

control, and general maintenance. The clinics met standards, and the environments were 

generally clean and safe. 

Emergency Management

VHA Handbook 1006.1 requires each CBOC to have a local policy or SOP defining how 

medical and MH emergencies are handled. Both CBOCs had policies that outlined 

management of medical and MH emergencies. Our interviews revealed staff at each 

facility articulated responses that accurately reflected the local emergency response 

guidelines. 

Patient Satisfaction 

The SHEP results for FY 2008 are displayed in Figures 6 and 7. 

 

VA Office of Inspector General 20 
CBOC Reviews: Macon, Albany, Beaver Dam, Rockford, Sioux City, Aberdeen, Waterloo, and Galesburg 

Trip Pak Report - STA5 Level 

Patient Perceptions of Care 

2008 SHEP Performance Measures 

YTD Through September 2008 

Performance 

Measure (SHEP 

question #) 

Station 

Number 

Facility 

Name 

Data 

Type 

FY08 

Qtr 4 

FY08 

Qtr 3 

FY08 

Qtr 2 

VISN 

FY08, 

Qtr 4 

National 

FY08, 

Qtr 4 

(Q56) - Outpatients 

(percent Very 

Good, Excellent) 

438 Sioux Falls Mean 

Score 

84.7 91.7 81.9 82.2 78.5

N= 90 73 79 3,305 54,400

438GC Sioux City 78.5 78.4 96.2 

N= 74 74 78 

438GD Aberdeen 84.4 69.8 75.2 

N= 93 73 82 

Figure 6. Outpatient Overall Quality 

The Sioux City CBOC scores surpassed the parent facility scores in the “overall quality” 

measure in the 2nd Qtr. Although the scores were lower in the 3rd and 4th Qtrs, the clinic 

still met the VHA target of 77. The Aberdeen CBOC scored below the target measure of 

77 percent for two out of three quarters in the “overall quality” measure. The decline in 

“overall quality” scores were attributed to staff instability, which was resolved with an 

intensive recruitment program. 

Trip Pak Report - STA5 Level 

Patient Perceptions of Care 

2008 SHEP Performance Measures 

YTD Through September 2008 

Performance 

Measure (SHEP 

question #) 

Station 

Number 

Facility 

Name 

Data 

Type 

FY08 

Qtr 4 

FY08 

Qtr 3 

FY08 

Qtr 2 

VISN 

FY08, 

Qtr 4 

National FY08, 

Qtr 4 

(Q6) - (percent 

less than/equal to 

20 minutes) 

438 Sioux Falls Mean 

Score 

85.8 77 81.4 84.9 77.3 

 N= 90 75 79 3,403 55,407 

438GC Sioux City 94.4 91.9 97.2 

N= 79 72 86 

438GD Aberdeen 93.9 93.8 91.7 

N= 92 75 89 

Figure 7. Provider Wait Times 

Both Sioux City and Aberdeen exceeded the target measure of “provider wait times” for 

all quarters. The scores significantly exceeded the parent facility. 

VA Office of Inspector General 21 
CBOC Reviews: Macon, Albany, Beaver Dam, Rockford, Sioux City, Aberdeen, Waterloo, and Galesburg 

D. VISN 23, Iowa City VAMC – Waterloo and Galesburg 

Quality of Care Measures 

The Waterloo CBOC scores exceeded the parent facility on DM foot inspection, pedal 

pulses, foot sensory exam, and retinal eye exam, and PTSD screening, while they were 

slightly lower on hyperlipidemia, low-density lipoprotein cholesterol (LDL-C) screen, 

and renal testing. The Galesburg CBOC scores exceeded the parent facility for all 

measures. (See Appendix L.)

Credentialing and Privileging 

We reviewed the C&P files of five providers and the personnel folders of four nurses at 

both the Waterloo and Galesburg CBOCs. All providers possess a full, active, current, 

and unrestricted license. All nurses’ license and education requirements were verified 

and documented. We identified the following areas that needed improvements: 

Credentialing

Declaration of Health 

The medical center obtained the providers’ health declarations during the initial and 

reappraisal process, as required by VHA Handbook 1100.19, but failed to scan the health 

declarations for all providers into the VetPro system as required. Failure to scan these 

documents into the VetPro system has the potential of decreasing the efficiency and 

accuracy of the credentialing process. Because hard copies of the health declarations 

were available for review during the reappraisal process and senior managers have agreed 

to scan the declarations into the VetPro system, we did not make a recommendation. 

Privileging

Clinical Privileges 

The physicians’ privileges at both CBOCs were based on a category system, and there 

was no difference in the clinical privileges of primary care providers (PCP) and general 

medicine providers. Each category described the activity the provider was qualified to 

perform. For example, Category I would afford the practitioner to treat “uncomplicated 

illness or problems with low risk to the patient,” and Category II practitioners would 

provide “general medical care treatment of medical diseases including care in the 

intensive care unit.” Both categories permitted the practitioners to provide urgent care. 

The PCPs we reviewed were full-time staff at the CBOCs and were granted Category II 

privileges. Two PCPs were also granted skin biopsy and/or sigmoidoscopy privileges; 

although, these procedures were not performed at the CBOCs. According to VHA 

VA Office of Inspector General 22 
CBOC Reviews: Macon, Albany, Beaver Dam, Rockford, Sioux City, Aberdeen, Waterloo, and Galesburg 

VA Office of Inspector General 23 

Handbook 1100.19, only privileges for procedures actually provided by the VA facility 

may be granted to a practitioner. 

Performance Improvement 

According to the medical center’s medical bylaws, each renewal or revision of privileges 

is based on a reappraisal. Evaluation of professional performance, judgment, clinical 

and/or technical competence, and skills are to be based in part on results of medical 

center performance improvement (PI) information and activities. Additionally, each 

service will monitor the performance of its active staff and utilize that information at the 

time of reappraisal. 

The service chief did maintain provider profiles on all practitioners. The items in the 

provider profiles included complaints, patient satisfaction, and individual patient record 

reviews (5 to 10 records). To evaluate the providers’ clinical competency, each patient 

record was peer reviewed; however, there were no developed criteria to conduct these 

reviews.6

 

Furthermore, we did not find a written plan with service-specific (Primary Care) 

competency criteria for Ongoing Professional Practice Evaluation (OPPE). Ongoing 

reviews conducted by service chiefs must be comprised of activities with defined criteria 

that emphasize the facility’s PI plan, appropriateness of care, patient safety, and desired 

outcomes. VHA regulations require a thorough written plan with specific competency 

criteria for OPPE for all privileged physicians. 

Recommendation 12. We recommended that the VISN 23 Director ensure that the Iowa 

City VAMC Director requires physician privileges are appropriate to the procedures 

performed at both the Waterloo and Galesburg CBOCs. 

The VISN and VAMC Directors concurred with our finding and recommendation. The 

Deputy Director for Primary Care will ensure providers are granted privileges 

commensurate with actual services that they may perform at the CBOC site. The 

improvement plans are acceptable, and we will follow up on the planned actions until 

they are completed. 

Recommendation 13. We recommended that the VISN 23 Director ensure that the Iowa 

City VAMC Director requires that the OPPE plan, OPPE data, and the privileging 

process are managed in accordance with VHA requirements for both the Waterloo and 

Galesburg CBOCs. 

 

6

 Peer review is defined to include critical reviews of care performed by a peer and/or group of peers. The review is 

given a Level 1, 2, or 3 rating. A Level 2 and 3 rating indicates that most experienced, competent practitioners 

“might” or “would,” respectively, have managed the case differently. 
CBOC Reviews: Macon, Albany, Beaver Dam, Rockford, Sioux City, Aberdeen, Waterloo, and Galesburg 

VA Office of Inspector General 24 

The VISN and VAMC Directors concurred with our finding and recommendation. Initial 

privileging and re-credentialing process is being reviewed and updated to reflect the 

specific daily practice of each provider. The re-credentialing process will include 

random and focus peer reviews. The reviews will assess appropriateness of care, patient 

safety, and desired outcomes. The improvement plans are acceptable, and we will follow 

up on the planned actions until they are completed. 

Environment and Emergency Management 

Environment of Care

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

control, and general maintenance. Both CBOCs’ internal EOC were basically clean and 

well maintained. The CBOCs met most standards, and the environment was safe. 

However, we identified the following areas that needed improvement: 

Information Technology Vulnerability 

At the Galesburg CBOC, we found a room utilized as the information technology (IT) 

clinic network center and housekeeping storage (equipment and supplies). Although the 

room was locked, the network center was not secured because access to this room was 

not monitored. The housekeeping and nursing staff had a key to the room. VA 

Handbook 65007

 states that access to these locations are limited to authorized IT staff, 

unless accompanied by authorized staff. Moreover, IT staff will coordinate and authorize 

access to co-located equipment areas, which is managed or supervised by a department 

other than IT. 

Handicap Access 

The Waterloo CBOC was not equipped with an automatic door opener or door bell to 

assist patients accessing the clinic area. The staff indicated that patients who required 

assistance were usually escorted to their appointments, and the escorts would open the 

door so the patient could gain entry. Although managers stated that the door was lightweight and did not pose as an obstacle to entry, we determined that a patient in a 

wheelchair/walker would not be able to hold the door open and maneuver their assistive 

device. 

Panic Alarms 

Both CBOCs provide MH services. The staff were able to describe several processes 

utilized to ensure a safe environment and a rapid response to a MH emergency. Selected 

staff at both CBOCs had a pull-cord alarm device. The pull-cord alarm device tested at 

the Waterloo CBOC was not audible to staff members in other areas of the clinic; 

 

7

 VA Handbook 6500, Information Security Program, September 18, 2007. 
CBOC Reviews: Macon, Albany, Beaver Dam, Rockford, Sioux City, Aberdeen, Waterloo, and Galesburg 

therefore, staff notification and support would not readily be available in the event of an 

emergency. 

Sharps Containers 

The exam rooms at the Waterloo CBOC were supplied with 2-gallon sharps containers 

that were mounted above the eye level of most staff members. The container’s lid was 

not designed to limit accidental or intentional access to used sharp items. Moreover, the 

containers were opaque; therefore, staff could not easily identify when the containers 

were in need of disposal. 

Wall Penetration 

At the Galesburg CBOC, we found a large wall penetration behind a sink in a soiled 

utility room. The penetration was large enough to expose several plumbing pipes. 

Because plans to repair the penetration were made during our site visit, we did not make 

a recommendation. 

Recommendation 14. We recommended that the VISN 23 Director ensure that the Iowa 

City VAMC Director conduct an IT network security assessment and correct any 

vulnerabilities at the Galesburg CBOC. 

The VISN and VAMC Directors concurred with our finding and recommendation. 

Relocation of the Galesburg CBOC is in progress, and the new site will include an 

independent IT closet with restricted access. In the interim, only those persons who have 

been granted access to the IT closet will possess a key to the closet. The improvement 

plans are acceptable, and we will follow up on the planned actions until they are 

completed. 

Recommendation 15. We recommended that the VISN 23 Director ensure that the Iowa 

City VAMC Director improve access for disabled veterans at the Waterloo CBOC. 

The VISN and VAMC Directors concurred with our finding and recommendation. A 

doorbell is scheduled to be installed at the clinic entrance, and signage will be posted to 

make veterans aware to ring the bell if assistance is needed with the door. The 

improvement plans are acceptable, and we will follow up on the planned actions until 

they are completed. 

Recommendation 16. We recommended that the VISN 23 Director ensure that the Iowa 

City VAMC Director evaluate the effectiveness of the panic alarm system at the 

Waterloo CBOC. 

The VISN and VAMC Directors concurred with our finding and recommendation. The 

personal panic alarms used at the Galesburg CBOC were deemed acceptable; therefore, 

the same panic alarms have been sent to the Waterloo CBOC staff. The improvement 

VA Office of Inspector General 25 
CBOC Reviews: Macon, Albany, Beaver Dam, Rockford, Sioux City, Aberdeen, Waterloo, and Galesburg 

plans are acceptable, and we will follow up on the planned actions until they are 

completed. 

Recommendation 17. We recommended that the VISN 23 Director ensure that the Iowa 

City VAMC Director requires that sharps containers can be accessed safely by the staff at 

the Waterloo CBOC. 

The VISN and VAMC Directors concurred with our finding and recommendation. All 

wall-mounted sharps containers will be relocated to ensure they can be accessed safely by 

the staff. The improvement plans are acceptable, and we will follow up on the planned 

actions until they are completed. 

Emergency Management

VHA Handbook 1006.1 requires each CBOC to have a local policy or SOP defining how 

medical and MH emergencies are handled. Our interviews revealed staff at each facility 

articulated responses that accurately reflected the local emergency response guidelines. 

Patient Satisfaction

SHEP results for FY 2008 are displayed in Figures 8 and 9. 

Trip Pak Report - STA5 Level 

Patient Perceptions of Care 

2008 SHEP Performance Measures 

YTD Through September 2008 

Performance 

Measure (SHEP 

question #) 

Station 

Number 

Facility 

Name 

Data 

Type 

FY08 

Qtr 4 

FY08 

Qtr 3 

FY08 

Qtr 2 

VISN 

FY08, 

Qtr 4 

National 

FY08, 

Qtr 4 

(Q56) - Outpatients 

(percent Very 

Good, Excellent) 

636A8 Iowa City Mean 

Score 

85.4 73.9 89.3 82.2 78.5

N= 84 84 74 3,305 54,400

636GH Waterloo 77.9 82.8 80.4 

 N= 75 65 86 

636GI Galesburg 84.6 88.7 86.2 

N= 82 85 76 

Figure 8. Outpatient Overall Quality 

Both CBOCs met the VHA target score of 77 in “overall quality” in all quarters. Both 

Waterloo and Galesburg scored slightly lower than the parent facility except in the 

3rd Qtr, and both CBOCs’ scores exceeded the parent facility. 

VA Office of Inspector General 26 
CBOC Reviews: Macon, Albany, Beaver Dam, Rockford, Sioux City, Aberdeen, Waterloo, and Galesburg 

VA Office of Inspector General 27 

Trip Pak Report - STA5 Level 

Patient Perceptions of Care 

2008 SHEP Performance Measures 

YTD Through September 2008 

Performance 

Measure (SHEP 

question #) 

Station 

Number 

Facility 

Name 

Data 

Type 

FY08 

Qtr 4 

FY08 

Qtr 3 

FY08 

Qtr 2 

VISN 

FY08, 

Qtr 4 

National FY08, 

Qtr 4 

(Q6) - (percent 

Less than/equal 

to 20 minutes) 

636A8 Iowa City Mean 

Score 

67.5 69.5 70 84.9 77.3 

N= 87 82 77 3,403 55,407 

636GH Waterloo 

84.9 94.5 92.4 

 

 N= 81 71 87 

636GI Galesburg 93 95.3 93.1 

N= 83 87 81 

Figure 9. Provider Wait Times 

The Waterloo and Galesburg CBOCs far exceeded the parent facility SHEP score. They 

also exceeded the VHA target goal of 77 percent in all quarters reviewed. 
CBOC Reviews: Macon, Albany, Beaver Dam, Rockford, Sioux City, Aberdeen, Waterloo, and Galesburg 

Appendix A 

VISN 7 Director Comments 

VA Office of Inspector General 28 

Department of 

Veterans Affairs Memorandum

Date: October 30, 2009 

From: Director, Veterans Integrated Service Network 7 (10N7) 

Subject: Healthcare Inspection – CBOC Reviews: Macon and Albany, 

GA

To: Director, CBOC/Vet Center Program Review, Office of 

Healthcare Inspections (54F) 

 I concur with the recommendations and action plans 

proposed in the report. 

 
CBOC Reviews: Macon, Albany, Beaver Dam, Rockford, Sioux City, Aberdeen, Waterloo, and Galesburg 

Appendix B 

Dublin VAMC Director Comments 

VA Office of Inspector General 29 

Department of 

Veterans Affairs Memorandum

Date: October 29, 2009 

From: Director, Dublin VAMC (557/00) 

Subject: Healthcare Inspection – CBOC Reviews: Macon and Albany, 

GA

To: Director, Veterans Integrated Service Network 7 (10N7) 

 
CBOC Reviews: Macon, Albany, Beaver Dam, Rockford, Sioux City, Aberdeen, Waterloo, and Galesburg 

Dublin VAMC 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 Recommendations

Recommendation 1. We recommended that the VISN 7 Director ensure 

that the Dublin VAMC Director requires that the contract requirements for 

physicians are met or aligned with VHA requirements at the Macon and 

Albany CBOCs. 

Concur Target Completion Date: 1 Dec 09

The facility has submitted a request for modification to the contract officer 

to change the verbiage of the requirements for physicians to be board 

certified OR board eligible. 

Recommendation 2. We recommended that the VISN 7 Director ensure 

that the Dublin VAMC Director requires that contract providers at the 

Macon and Albany CBOCs are privileged according to VHA policy. 

Concur Target Completion Date: 1 Dec 09

The Medical Center Chief of Staff has changed the privileging policy for 

CBOC providers and developed a different privileging form for CBOC 

providers. 

Recommendation 3. We recommended that the VISN 7 Director ensure 

that the Dublin VAMC Director requires that clinical managers review the 

privileges that have been granted to clinical staff and grant privileges that 

are consistent with providers’ practices at the Macon and Albany CBOCs. 

Concur Target Completion Date: 1 Dec 09

The Medical Center Chief of Staff has changed the privileging policy for 

CBOC providers and developed a different privileging form for CBOC 

providers. 

VA Office of Inspector General 30 
CBOC Reviews: Macon, Albany, Beaver Dam, Rockford, Sioux City, Aberdeen, Waterloo, and Galesburg 

Recommendation 4. We recommended that the VISN 7 Director ensure 

that the Dublin VAMC Director requires a functional panic alarm system 

for the Albany CBOC. 

Concur Target Completion Date: 1 Dec 09

The COTR requested through the Contract Officer for the Contractor to 

remove the inoperable panic alarm system at Albany CBOC however, the 

clinic has individual alert monitors worn by key staff. 

Recommendation 5. We recommended that the VISN 7 Director ensure 

that the Dublin VAMC Director provides contract oversight and 

enforcement in accordance with the terms and conditions as stated in the 

contract for the Macon and Albany CBOCs. Specifically, we 

recommended that the following measures be taken: 

A. Contracting officers should review key contractual provisions with 

the COTRs and ensure that the COTRs understand the terms of the contract 

and criteria on which contract performance is measured. 

B. Contracting officers should monitor the COTR’s oversight by 

evaluating the evidence that the COTR’s review and approval of contractor 

invoices is in compliance with terms of the contract. COTRs should retain 

evidence of their review or be able to identify source documents/reports as 

evidence of their review. 

C. COTRs should ensure that contractor performance measures, 

including incentives and negative incentives, are evaluated against the 

criterion established in the contract. 

D. Contractor invoices should be received in electronic format 

(Microsoft Access or Excel) in addition to paper documents to facilitate 

invoice analysis. 

Concur Target Completion Date: 1 Dec 09

The COTR is reviewing the provisions of the contract and developing new 

quality indicators that are easily quantifiable, and will monitor monthly in 

accordance with the contract. Additionally, the COTR will maintain a 

working file of evaluation evidence that complies with the terms of the 

contract. The COTR will work through the CO to ensure both soft/hard 

copies of the invoices are received timely to facilitate the invoice analysis 

and payment. 

VA Office of Inspector General 31 
CBOC Reviews: Macon, Albany, Beaver Dam, Rockford, Sioux City, Aberdeen, Waterloo, and Galesburg 

VA Office of Inspector General 32 

Recommendation 6. We recommended that the VISN 7 Director ensure 

that the Dublin VAMC Director provide Sterling with a current list of 

inactivated enrollees to prevent future overcharges on billings for the 

Macon and Albany CBOCs. 

Concur Target Completion Date: 1 Dec 09

The COTR is revising the process of recognize inactivated enrollee’s and 

alert the contractor in a monthly basis prior to invoice completion. 
CBOC Reviews: Macon, Albany, Beaver Dam, Rockford, Sioux City, Aberdeen, Waterloo, and Galesburg 

Appendix C 

VISN 12 Director Comments 

VA Office of Inspector General 33 

Department of 

Veterans Affairs Memorandum

Date: October 26, 2009 

From: Director, Veterans Integrated Service Network 12 

(10N12) 

Subject: Healthcare Inspection – CBOC Reviews: Beaver Dam, WI 

and Rockford, IL

To: Director, CBOC/Vet Center Program Review, Office of 

Healthcare Inspections (54F) 

1. Please find attached the response resulting from the reviews 

conducted at the Beaver Dam and Rockford CBOC’s. 

2. I have reviewed the action plans and concur. 

Jeffrey A. Murawsky, M.D. 
CBOC Reviews: Macon, Albany, Beaver Dam, Rockford, Sioux City, Aberdeen, Waterloo, and Galesburg

Appendix D 

Madison VAMC Director Comments

VA Office of Inspector General 34 

Department of 

Veterans Affairs Memorandum

Date: October 26, 2009 

From: Director, Madison VAMC (607/00) 

Subject: Healthcare Inspection – CBOC Reviews: Beaver Dam, WI 

and Rockford, IL

To: Director, Veterans Integrated Service Network 12 

(10N12) 

1. Thank you for the opportunity to review the draft 

report on the Healthcare Inspection – CBOC 

Reviews: Beaver Dam, WI and Rockford, IL. 

2. I have reviewed the document and concur with the 

recommendations. Corrective action plans have 

been established with planned completion dates, as 

detailed in the attached report. 

DEBORAH A. THOMPSON 

 DIRECTOR 

 

 
CBOC Reviews: Macon, Albany, Beaver Dam, Rockford, Sioux City, Aberdeen, Waterloo, and Galesburg

Madison VAMC 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 Recommendations

Recommendation 7. We recommended that the VISN 12 Director ensure 

that the Madison VAMC Director requires all computer stations at the 

Rockford CBOC are locked when not in use. 

Concur Target Completion Date: 10/13/09

The importance of privacy and security, specifically logging off computer 

terminals when staff walk away from their computers, was reiterated at the 

Rockford CBOC all employee staff meeting on September 17, 2009. 97% 

of staff at the Madison VA Hospital and clinics completed their Cyber 

Security (information security) and Privacy Awareness Training during FY 

09. On October 13, 2009 a national policy “EIE FDCC User Settings V2” 

was implemented by our facility IT department. This policy, the Federal 

Desktop Computer Configuration, mandates new Network settings for all 

medical center computers to comply with Security Standards. This policy 

has an automatic “LOG OFF” for a PC when sitting idle for fifteen minutes. 

There is a warning and a 60 second countdown before the automatic logoff. 

An all employee email was sent out to staff to explain the rationale for the 

change. This will eliminate the finding of having an open computer when 

left idle. 

Recommendation 8. We recommended that the VISN 12 Director ensure 

that the Madison VAMC Director requires PII be maintained in a more 

secure manner at the Rockford CBOC. 

Concur Target Completion Date: 9/17/09

Due to space constraints, it was decided that the staff mailboxes would 

remain in the staff break room. On September 17, 2009 the Rockford 

CBOC locked the staff break room. This decision was discussed at the 

CBOC staff meeting held 9/17/09, with rationale explained. The 

importance of maintaining confidential information in a secured 

environment (i.e. locked break room) has been reiterated regularly at 

weekly staff meetings. On 10/1/09 all mail going between the CBOC and 

parent facility is placed in locked bins that are kept in the staff break room. 

VA Office of Inspector General 35 
CBOC Reviews: Macon, Albany, Beaver Dam, Rockford, Sioux City, Aberdeen, Waterloo, and Galesburg

VA Office of Inspector General 36 

Since this plan was implemented, there has been signage posted to ensure 

break room door is closed and locked. 

Recommendation 9. We recommended that the VISN 12 Director ensure 

that the Madison VAMC Director requires that Beaver Dam CBOC 

develops a local policy for medical emergencies that reflects the current 

practice and capability of the CBOC. 

Concur Target Completion Date: 12/31/09

The local policy for medical emergencies (cardiac, respiratory, or at the 

CBOC is to contact 911. The nursing “Protocol for Treatment of 

Hypoglycemia “will be modified to reflect a decision point for inpatient vs. 

outpatient care. Outpatient care will follow through protocol to point of 

awake and responsive and able to take PO. If patient is obtunded or unable 

to swallow 911 would be contacted. This is a protocol that requires Chief 

of Staff Approval. 
CBOC Reviews: Macon, Albany, Beaver Dam, Rockford, Sioux City, Aberdeen, Waterloo, and Galesburg 

Appendix E 

VISN 23 Director Comments 

VA Office of Inspector General 37 

Department of 

Veterans Affairs Memorandum

Date: October 22, 2009 

From: Director, Veterans Integrated Service Network 23 

(10N23) 

Subject: Healthcare Inspection – CBOC Review: Sioux City, IA; 

Aberdeen, SD; Waterloo, IA; and Galesburg, IL 

To: Director, CBOC/Vet Center Program Review, Office of 

Healthcare Inspections (54F) 

 I have reviewed the recommendations and concur with the 

planned actions and target due dates. 

 (original signed by:) 

CYNTHIA BREYFOGLE, FACHE
CBOC Reviews: Macon, Albany, Beaver Dam, Rockford, Sioux City, Aberdeen, Waterloo, and Galesburg

Appendix F 

Sioux Falls VAMC Director Comments 

VA Office of Inspector General 38 

Department of 

Veterans Affairs Memorandum

Date: October 21, 2009 

From: Director, Sioux Falls VAMC (438/00) 

Subject: Healthcare Inspection – CBOC Review: Sioux City, IA and 

Aberdeen, SD 

To: Director, Veterans Integrated Service Network 23 (10N23) 

1. We appreciate the opportunity to review the on-site 

Healthcare Inspection report for the assessment conducted at 

the Sioux City and Aberdeen CBOCs on September 15-17, 

2009. 

2. Attached are comments regarding actions that are currently in 

process to improve and resolve non-compliance in the areas 

cited. 

3. We would like to extend our appreciation to the IG team 

members for their professionalism. Their collegial manner 

resulted in a beneficial review for the medical center. 

(original signed by:) 

Paul D. Bockelman 
CBOC Reviews: Macon, Albany, Beaver Dam, Rockford, Sioux City, Aberdeen, Waterloo, and Galesburg

Sioux Falls VAMC 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 Recommendations

Recommendation 10. We recommended that the VISN 23 Director ensure 

that the Sioux Falls VAMC Director requires that clinical managers grant 

privileges that are consistent with providers’ practices and with the clinical 

setting at the Aberdeen CBOC. 

Concur Target Completion Date: October 26, 2009

1. Credentialing Coordinator to request all CBOC Medical Directors to 

review the CBOC provider privileges and submit recommended 

changes based on their clinical setting to PSB members by October 23, 

2009. 

2. Professional Standards Board (PSB) to review all CBOC providers’ 

current privileges on October 23, 2009. 

3. Based on the review and CBOC clinical setting, privileges to be revised 

as appropriate at PSB meeting on October 23, 2009. 

4. Revisions to be documented in the PSB minutes by the Credentialing 

Coordinator on October 23, 2009. 

5. Credentialing Coordinator to notify the providers in writing of their 

privilege changes by October 26, 2009. 

Recommendation 11. We recommended that the VISN 23 Director ensure 

that the Sioux Falls VAMC Director requires that when reprivileging, 

practitioner data be compared to aggregate data of those privileged 

practitioners who hold the same or comparable privileges at the Sioux City 

and Aberdeen CBOCs. 

Concur Target Completion Date: December 18, 2009

1. Professional Standards Board to approve the recommended revisions to 

the practitioner file data format to include an area for the service chief to 

VA Office of Inspector General 39 
CBOC Reviews: Macon, Albany, Beaver Dam, Rockford, Sioux City, Aberdeen, Waterloo, and Galesburg

VA Office of Inspector General 40 

document his/her review of the practitioner’s aggregate data and to 

indicate with an asterisk which indicators have de-identified aggregated 

data for comparison on October 23, 2009. 

2. Once approved, all practitioner file data forms to be revised with the 

comment section for the service chief to document his/her review of the 

practitioner’s data as compared to aggregate comparable practitioner’s 

data by October 23, 2009. 

3. Each Service/Service Line leadership, along with quality management 

staff, to identify relevant practitioner specific data on the current 

practitioner forms that have available aggregate data for practitioners 

who hold the same or comparable privileges by October 30, 2009. 

4. The available de-identified comparable aggregate data will be 

acknowledged on each of the practitioner file forms with an asterisk by 

October 30, 2009. 

5. Service/Service Line leadership, along with quality management staff 

will develop a format for reporting the de-identified aggregate data 

comparisons for the selected indicators by November 16, 2009. 

6. Process to be imitated for de-identified aggregate data to be attached to 

each practitioner’s provider form when re-privileged for review and 

comment by the Service/Service Line chief, effective December 4, 

2009. 

7. Process to be initiated by Credentialing Coordinator to document in the 

PSB minutes the review of the de-identified aggregate data when the 

practitioner is re-privileged effective December 4, 2009. 
CBOC Reviews: Macon, Albany, Beaver Dam, Rockford, Sioux City, Aberdeen, Waterloo, and Galesburg

Appendix G 

Iowa City VAMC Director Comments 

VA Office of Inspector General 41 

Department of 

Veterans Affairs Memorandum

Date: October 21, 2009 

From: Director, Iowa City VAMC (636A8/00) 

Subject: Healthcare Inspection – CBOC Review: Waterloo, IA and 

Galesburg, IL 

To: Director, Veterans Integrated Service Network 23 (10N23) 

 1. Attached is our response to the reviews of two Iowa 

City VA Medical Center CBOC (Waterloo, Iowa; 

Galesburg, Illinois) 

 2. If you have any questions regarding this response, 

please contact me at 319-339-7100. 

BARRY D. SHARP 
CBOC Reviews: Macon, Albany, Beaver Dam, Rockford, Sioux City, Aberdeen, Waterloo, and Galesburg

Iowa City VAMC 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 Recommendations

Recommendation 12. We recommended that the VISN 23 Director ensure 

that the Iowa City VAMC Director requires physician privileges are 

appropriate to the procedures performed at both the Waterloo and 

Galesburg CBOCs. 

Concur Target Completion Date: February 1, 2010

Facility (Deputy Director for Primary Care) will ensure providers are 

granted privileges commensurate with actual services that they may 

perform at the CBOC site. 

Recommendation 13. We recommended that the VISN 23 Director ensure 

that the Iowa City VAMC Director requires that the OPPE plan, OPPE 

data, and the privileging process are managed in accordance with VHA 

requirements for both the Waterloo and Galesburg CBOCs. 

Concur Target Completion Date: December 30, 2009

Initial privileging and re-credentialing process is being reviewed and 

updated to reflect the specific daily practice of each provider. 

Re-credentialing process will include a random peer review of 3 encounters 

per provider and a focused peer review of 2 condition-specific encounters 

per provider as determined by service line leadership in order to assess 

appropriateness of care, patient safety, and desired outcomes. 

Recommendation 14. We recommended that the VISN 23 Director ensure 

that the Iowa City VAMC Director conduct an IT network security 

assessment and correct any vulnerabilities at the Galesburg CBOC. 

Concur Target Completion Date: November 6, 2009

VA Office of Inspector General 42 
CBOC Reviews: Macon, Albany, Beaver Dam, Rockford, Sioux City, Aberdeen, Waterloo, and Galesburg

VA Office of Inspector General 43 

Relocation of this CBOC site is in progress; the new clinic site will include a

dedicated IT closet with restricted access. In the interim, only those persons 

who have been granted access to the IT closet will possess a key to the closet. 

The Standard Operating Procedure number OIT-09-11, office of information 

& technology communications rooms non-IT personnel access, dated 

February 2009, is being updated to include the three staff from the Galesburg 

CBOC who have been granted that access.

Recommendation 15. We recommended that the VISN 23 Director ensure 

that the Iowa City VAMC Director improve access for disabled veterans at 

the Waterloo CBOC. 

Concur Target Completion Date: November 15, 2009

Assessment completed and permission from building owner has been 

obtained to install a doorbell at the clinic entrance. Installation date is set 

for 11/6/09. Signage will be posted to make veterans aware to ring the bell 

if assistance is needed with the door. Staff has been informed of the action 

plan and will assist veterans as needed. 

Recommendation 16. We recommended that the VISN 23 Director ensure 

that the Iowa City VAMC Director evaluate the effectiveness of the panic 

alarm system at the Waterloo CBOC. 

Concur Target Completion Date: Complete

Personal panic alarms used at the Galesburg CBOC were tested at the time 

of the survey and were deemed acceptable; the same personal panic alarms 

have been sent to the Waterloo CBOC staff. 

Recommendation 17. We recommended that the VISN 23 Director ensure 

that the Iowa City VAMC Director requires that sharps containers can be 

accessed safely by the staff at the Waterloo CBOC. 

Concur Target Completion Date: November 3, 2009

All but three of the wall-mounted sharps containers have been relocated to 

52-56 inches (top of container to floor); the three remaining will be 

completed with the laborers next site visit to the CBOC. 
CBOC Reviews: Macon, Albany, Beaver Dam, Rockford, Sioux City, Aberdeen, Waterloo, and Galesburg

Appendix H 

CBOC Characteristics 

CBOC Station Number CBOC Name Parent VA Specialty Care Podiatry GastrointestinalPhysical Therapy Substance Abuse Program Diabetes Self Management Neurology/TBI 

557GA Macon, GA Dublin, GA Yes Yes No No No No No

557GB Albany, GA Dublin, GA No No No No No No No

607GE Beaver Dam, WI Madison, WI No No No No No No No

607HA Rockford, IL Madison, WI Yes Yes Yes Yes No No Yes 

438GC Sioux City, IA Sioux Falls, SD No No No No No No No

438GD Aberdeen, SD Sioux Falls, SD No No No No No No No

636GH Waterloo, IA Iowa City, IA Yes No No No Yes Yes No

636GI Galesburg, IL Iowa City, IA Yes No No No Yes Yes No

Specialty Care Services 

CBOC Station Number CBOC Name Parent VA Laboratory (draw blood) Spirometry Onsite Pharmacy EKG Social Services Dietary Services Tele-medicine 

557GA Macon, GA Dublin, GA No No No Yes Yes Yes No 

557GB Albany, GA Dublin, GA No No No Yes No Yes No 

607GE Beaver Dam, WI Madison, WI Yes No No Yes No No No 

607HA Rockford, IL Madison, WI Yes No Yes Yes Yes Yes No 

438GC Sioux City, IA Sioux Falls, SD Yes No No Yes No No Yes 

438GD Aberdeen, SD Sioux Falls, SD Yes No No Yes Yes No No 

636GH Waterloo, IA Iowa City, IA Yes Yes No Yes No Yes Yes 

636GI Galesburg, IL Iowa City, IA Yes Yes No Yes No Yes Yes 

Onsite Services 

CBOC Station Number CBOC Name Parent VA Mental Health Care Primary Care Physicians Psychologist Psychiatrist Nurse Practitioner Social Worker Tele-mental health 

557GA Macon, GA Dublin, GA Yes No Yes No Yes Yes No 

557GB Albany, GA Dublin, GA Yes No Yes Yes No Yes No 

607GE Beaver Dam, WI Madison, WI Yes Yes No Yes Yes Yes Yes 

607HA Rockford, IL Madison, WI Yes Yes No Yes Yes Yes Yes 

438GC Sioux City, IA Sioux Falls, SD Yes No Yes Yes No No Yes 

438GD Aberdeen, SD Sioux Falls, SD Yes No Yes Yes No No Yes 

636GH Waterloo, IA Iowa City, IA Yes Yes No Yes No Yes Yes 

636GI Galesburg, IL Iowa City, IA Yes Yes No Yes No Yes Yes 

Mental Health Services

VA Office of Inspector General 44 
CBOC Reviews: Macon, Albany, Beaver Dam, Rockford, Sioux City, Aberdeen, Waterloo, and Galesburg CBOC Station Number CBOC Name Internal Medicine Physician Primary Care Physician Nurse Practitioner Physician Assistant Registered Nurse LPN Psychologist Pharmacist Social Worker Dietary Technologists Administrative/Cleri cal Other 

557GA Macon, GA No Yes Yes No No Yes Yes No Yes Yes No Yes No 

557GB Albany, GA No Yes No Yes No Yes No No Yes Yes Yes Yes No 

607GE 

Beaver Dam, 

WI No Yes Yes No Yes No No No Yes No No Yes No 

607HA Rockford, IL No Yes Yes No Yes Yes No Yes Yes Yes Yes Yes No 

438GC Sioux City, IA Yes Yes No Yes Yes Yes Yes No No No Yes Yes No 

438GD Aberdeen, SD No Yes Yes Yes Yes Yes Yes No Yes No Yes Yes Yes 

636GH Waterloo, IA No Yes No No Yes Yes No No Yes No No Yes Yes 

636GI Galesburg, IL No Yes No Yes Yes Yes No No Yes No No No Yes 

Disciplines Present at the CBOC 

CBOC Station Number CBOC Name Parent VA Urban/Rural 

Miles to Parent Facility 

Bus Taxi Voluntary services Tele-medicine 

557GA Macon, GA Dublin, GA Rural 60 Yes Yes Yes No 

557GB Albany, GA Dublin, GA Rural 98 Yes Yes Yes No 

607GE Beaver Dam, WI Madison, WI Rural 55 No Yes Yes No 

607HA Rockford, IL Madison, WI Urban 75 Yes Yes Yes No 

438GC Sioux City, IA Sioux Falls, SD Rural 87 Yes Yes Yes Yes 

438GD Aberdeen, SD Sioux Falls, SD Rural 203 No Yes Yes No 

636GH Waterloo, IA Iowa City, IA Urban 85.09 Yes Yes Yes Yes 

636GI Galesburg, IL Iowa City, IA Urban 111.38 Yes Yes No Yes 

Type of Location, Availability of Public 

 Transportation, and Participation in Tele-medicine 

VA Office of Inspector General 45 
CBOC Reviews: Macon, Albany, Beaver Dam, Rockford, Sioux City, Aberdeen, Waterloo, and Galesburg

Appendix I 

Quality of Care Measures 

Dublin VAMC – Macon and Albany 

Measure Facility 

Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 Percentage 

Hyperlipidemia 

Screen 

National 13,148 13,587 97 

557 Dublin 103 106 97 

 557GA Macon 33 34 97 

 557GB Albany 38 44 86 

Hyperlipidemia Screening, FY 2009 

Measure Facility Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 

Percentage 

DM – Outpatient Foot 

Inspection 

National 5,523 5,971 92 

557 Dublin 38 38 100 

557GA Macon 41 41 100 

557GB Albany 43 43 100 

DM Foot Inspection, FY 2009 

 Measure Facility Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 Percentage 

DM - Outpatient Foot 

Pedal Pulses 

National 5,395 5,971 90 

557 Dublin 38 38 100 

557GA Macon 41 41 100 

557GB Albany 43 43 100 

Foot Pedal Pulses, FY 2009 

Sensory Exam 

DM - Outpatient - Foot 

Sensory Exam Using 

Monofilament 

National 5,266 5,951 88 

557 Dublin 33 38 87 

557GA Macon 41 41 100 

557GB Albany 41 43 95 

Foot Sensory, FY 2009 

VA Office of Inspector General 46 
CBOC Reviews: Macon, Albany, Beaver Dam, Rockford, Sioux City, Aberdeen, Waterloo, and Galesburg

Measure Meets 

Target 

Facility Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 

Percentage 

DM – Retinal 

Eye Exam 

88 National 4,599 5,258 87 

88 557 Dublin 34 35 97 

557GA Macon 40 41 98 

557GB Albany 39 43 91 

Retinal Exam, FY 2009 

Measure Meets 

Target 

Facility Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 Percentage 

DM - LDL-C 95 National 4,990 5,209 96 

95 557 Dublin 34 35 97 

557GA Macon 40 41 98 

557GB Albany 39 43 91 

Lipid Profile, FY 2009 

Measure Meets 

Target 

Facility Qtr 1 

Numerator 

Qtr 1 

Denominator 

 Qtr 1 

Percentage 

DM - 

Renal 

Testing 

93 National 4,976 5,263 95 

93 557 Dublin 34 35 97 

557GA Macon 41 41 100 

557GB Albany 43 43 100 

Renal Testing, FY 2009

Measure Meets 

Target 

Facility Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 

Percentage 

Patient Screen 

with PC-PTSD 

90 National 4,751 4,987 95 

90 557 Dublin 83 83 100 

557GA Macon 12 12 100 

557GB Albany 12 12 100 

PTSD Screening, FY 2009 

VA Office of Inspector General 47 
CBOC Reviews: Macon, Albany, Beaver Dam, Rockford, Sioux City, Aberdeen, Waterloo, and Galesburg

Appendix J 

Quality of Care Measures 

Madison VAMC – Beaver Dam and Rockford 

Measure Facility 

Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 Percentage 

Hyperlipidemia 

Screen 

National 13,148 13,587 97 

607 Madison 97 101 96 

 607GE Beaver Dam 49 50 98 

 607HA Rockford 50 50 100 

Hyperlipidemia Screening, FY 2009 

Measure Facility Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 

Percentage 

DM – Outpatient Foot 

Inspection 

National 5,523 5,971 92 

607 Madison 26 33 79 

607GE Beaver Dam 35 37 95 

607HA Rockford 43 50 86 

DM Foot Inspection, FY 2009 

 Measure Facility Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 Percentage 

DM - Outpatient Foot 

Pedal Pulses 

National 5,395 5,971 90 

607 Madison 26 33 79 

607GE Beaver Dam 35 37 95 

607HA Rockford 43 50 86 

Foot Pedal Pulses, FY 2009 

Sensory Exam 

DM - Outpatient - Foot 

sensory exam using 

monofilament 

National 5,266 5,951 88 

607 Madison 26 33 79 

607GE Beaver Dam 35 37 95 

607HA Rockford 43 50 86 

Foot Sensory, FY 2009

VA Office of Inspector General 48 
CBOC Reviews: Macon, Albany, Beaver Dam, Rockford, Sioux City, Aberdeen, Waterloo, and Galesburg

Measure Meets 

Target 

Facility Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 

Percentage 

DM – Retinal 

Eye Exam 

88 National 4,599 5,258 87 

88 607 Madison 24 29 83 

607GE Beaver Dam 35 37 95 

607HA Rockford 41 50 82 

Retinal Exam, FY 2009 

Measure Meets 

Target

 

Facility Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 

Percentage 

DM - LDL-C 95 National 4,990 5,209 96 

95 607 Madison 29 30 97 

607GE Beaver Dam 36 37 98 

607HA Rockford 49 50 98 

Lipid Profile, FY 2009 

Measure Meets 

Target 

Facility Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 

Percentage 

DM - 

Renal 

Testing 

93 National 4,976 5,263 95 

93 607 Madison 30 30 100 

607GE Beaver Dam 37 37 100 

607HA Rockford 50 50 100 

Renal Testing, FY 2009 

Measure Meets 

Target

 

Facility Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 

Percentage 

Patient Screen 

with PC-PTSD 

90 National 4,751 4,987 95 

90 607 Madison 17 17 100 

607GE Beaver Dam 13 13 100 

607HA Rockford 20 20 100 

PTSD Screening, FY 2009 

VA Office of Inspector General 49 
CBOC Reviews: Macon, Albany, Beaver Dam, Rockford, Sioux City, Aberdeen, Waterloo, and Galesburg

Appendix K 

Quality of Care Measures 

Sioux Falls VAMC – Sioux City and Aberdeen 

Measure Facility 

Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 Percentage 

Hyperlipidemia 

Screen 

National 13,148 13,587 97 

438 Sioux Falls 106 107 99 

 438GC Sioux City 2 2 100 

 438GD Aberdeen 5 5 100 

Hyperlipidemia Screening, FY 2009 

Measure Facility Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 

Percentage 

DM – Outpatient Foot 

Inspection 

National 5,523 5,971 92 

438 Sioux Falls 42 52 81 

438GC Sioux City 50 50 100 

438GD Aberdeen 47 50 94 

DM Foot Inspection, FY 2009 

 Measure Facility Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 Percentage 

DM - Outpatient Foot 

pedal pulses 

National 5,395 5,971 90 

438 Sioux Falls 43 52 83 

438GC Sioux City 50 50 100 

438GD Aberdeen 43 50 86 

Foot Pedal Pulses, FY 2009 

Sensory Exam 

DM - Outpatient - 

Foot Sensory Exam 

Using Monofilament 

National 5,266 5,951 88 

438 Sioux Falls 41 52 79 

438GC Sioux City 49 50 98 

438GD Aberdeen 41 50 82 

Foot Sensory, FY 2009 

VA Office of Inspector General 50 
CBOC Reviews: Macon, Albany, Beaver Dam, Rockford, Sioux City, Aberdeen, Waterloo, and Galesburg 

Measure Meets 

Target 

Facility Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 

Percentage 

DM – 

Retinal 

Eye Exam 

88 National 4,599 5,258 87 

88 438 Sioux Falls 30 39 77 

438GC Sioux City 43 50 86 

438GD Aberdeen 31 50 62 

Retinal Exam, FY 2009 

Measure Meets 

Target 

Facility Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 

Percentage 

DM - LDL-C 95 4,990 5,209 96 

95 438 Sioux Falls 38 38 100 

438GC Sioux City 50 50 100 

438GD Aberdeen 49 50 98 

Lipid Profile, FY 2009 

Measure Meets 

Target 

Facility Qtr 1 

Numerator 

Qtr 1 

Denominator 

 Qtr 1 

Percentage 

DM - 

Renal 

Testing 

93 National 4,976 5,263 95 

93 438 Sioux Falls 36 39 92 

438GC Sioux City 49 50 98 

438GD Aberdeen 46 50 92 

Renal Testing, FY 2009 

Measure Meets 

Target 

Facility Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 Percentage 

Patient Screen 

with PC-PTSD 

90 National 4,751 4,987 95 

90 438 Sioux Falls 5 5 100 

438GC Sioux City 30 30 100 

438GD Aberdeen 22 25 88 

PTSD Screening, FY 2009 

VA Office of Inspector General 51 
CBOC Reviews: Macon, Albany, Beaver Dam, Rockford, Sioux City, Aberdeen, Waterloo, and Galesburg 

Appendix L 

VA Office of Inspector General 52 

Quality of Care Measures 

Iowa City VAMC – Waterloo and Galesburg 

Measure Facility 

Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 Percentage 

Hyperlipidemia 

Screen 

National 13,148 13,587 97 

636A8 Iowa City 83 87 95 

 636GH Waterloo 46 49 94 

636GI Galesburg 4 4 100 

Hyperlipidemia Screening, FY 2009 

Measure Facility Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 

Percentage 

DM – Outpatient Foot 

Inspection 

National 5,523 5,971 92 

636A8 Iowa City 43 49 88 

636GH Waterloo 49 50 98 

636GI Galesburg 46 46 100 

DM Foot Inspection, FY 2009 

 Measure Facility Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 Percentage 

DM - Outpatient Foot 

pedal pulses 

National 5,395 5,971 90 

636A8 Iowa City 41 49 84 

636GH Waterloo 50 50 100 

636GI Galesburg 43 46 94 

Foot Pedal Pulses, FY 2009 

Sensory Exam 

DM - Outpatient - 

Foot Sensory Exam 

Using Monofilament 

National 5,266 5,951 88 

636A8 Iowa City 38 49 78 

636GH Waterloo 49 50 98 

636GI Galesburg 45 46 98 

Foot Sensory, FY 2009 
CBOC Reviews: Macon, Albany, Beaver Dam, Rockford, Sioux City, Aberdeen, Waterloo, and Galesburg 

VA Office of Inspector General 53 

Measure Meets 

Target 

Facility Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 

Percentage 

DM – 

Retinal 

Eye Exam 

88 National 4,599 5,258 87 

88 636A8 Iowa City 35 41 85 

636GH Waterloo 42 50 84 

636GI Galesburg 43 46 94 

Retinal Exam, FY 2009 

Measure Meets 

Target 

Facility Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 

Percentage 

DM - LDL-C 95 National 4,990 5,209 96 

95 636A8 Iowa City 35 40 88 

636GH Waterloo 42 50 84 

636GI Galesburg 45 46 98 

Lipid Profile, FY 2009 

Measure Meets 

Target 

Facility Qtr 1 

Numerator 

Qtr 1 

Denominator 

 Qtr 1 

Percentage 

DM - 

Renal 

Testing 

93 National 4,976 5,263 95 

93 636A8 Iowa City 38 41 93 

636GH Waterloo 45 50 90 

636GI Galesburg 46 46 100 

Renal Testing, FY 2009 

Measure Meets 

Target 

Facility Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 Percentage 

Patient Screen 

with PC-PTSD 

90 National 4,751 4,987 95 

90 636A8 Iowa City 30 31 97 

636GH Waterloo 8 8 100 

636GI Galesburg 1 1 100 

PTSD Screening, FY 2009 
CBOC Reviews: Macon, Albany, Beaver Dam, Rockford, Sioux City, Aberdeen, Waterloo, and Galesburg

Appendix M 

OIG Contact and Staff Acknowledgments 

OIG Contact Marisa Casado, Director 

CBOC/Vet Center Program Review 

(727) 395-2416 

Acknowledgments Wachita Haywood, Associate Director 

Nancy Albaladejo, RN, MSA 

Jennifer Christensen, DPM 

Lin Clegg, Ph.D. 

Marnette Dhooghe, MS 

Kathy Gudgell, RN, JD 

Stephanie Hensel, RN, JD 

Zhana Johnson, CPA 

Anthony M. Leigh, CPA, CFE 

Jennifer Reed, RN 

Annette Robinson, MSN, MBA, HCM 

Thomas J. Seluzicki, CPA, CFE 

Marilyn Stones, Lead Program Specialist 

VA Office of Inspector General 54 
CBOC Reviews: Macon, Albany, Beaver Dam, Rockford, Sioux City, Aberdeen, Waterloo, and Galesburg

Appendix N 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, Veterans Integrated Service Network (10N7) 

Director, Veterans Integrated Service Network (10N12) 

Director, Veterans Integrated Service Network (10N23) 

Director, Dublin VAMC (557/00) 

Director, Madison VAMC (607/00) 

Director, Sioux Falls VAMC (438/00) 

Director, Iowa City VAMC (636A8/00) 

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: Roland W. Burris, Saxby Chambliss, Richard J. Durbin, Russell D. 

Feingold, Chuck Grassley, Tom Harkin, Johnny Isakson, Tim Johnson, Herb Kohl, 

John Thune 

U.S. House of Representatives: Sanford Bishop, Leonard Boswell, Bruce Braley, Phil 

Hare, Steve King, Tom Latham, David Loebsack, Donald Manzullo, Jim Marshall, Tom 

Petri, Stephanie Herseth Sandlin 

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

VA Office of Inspector General 55