Department of Veterans Affairs 

Office of Inspector General 

Healthcare Inspection 

Review of Selected Pharmacy 

Operations in Veterans Health 

Administration Facilities 

Report No. 07-03524-40 December 3, 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 
Review of Selected Pharmacy Operations in VHA Facilities 

Executive Summary 

VA Office of Inspector General, Office of Healthcare Inspections completed an 

evaluation of select pharmacy processes in Veterans Health Administration (VHA) 

medical facilities. The purpose of our review was to: (1) evaluate pharmacy controls 

related to security and management of controlled substances (CS), (2) determine whether 

medical facilities complied with local and VHA policies regarding pharmacy security and 

handling of CS, and (3) evaluate whether management controls of deterrence and 

detection of CS diversion were effective. 

We evaluated pharmacy internal physical environments, and we assessed whether 

pharmacies had processes to evaluate polypharmacy. We also determined whether 

pharmacies adhered to safety and infection control (IC) standards and whether pharmacy 

clean rooms complied with United States Pharmacopeia (USP) Chapter <797> guidelines 

for clean room construction. 

We performed this review at 43 VHA medical facilities during Combined Assessment 

Program reviews conducted across the country from January 1–December 31, 2008. 

Overall, pharmacies complied with VHA and IC guidelines, pharmacy physical security, 

and reporting requirements; however improvement is required to ensure full compliance 

with VHA regulations regarding CS inspection programs. 

We recommended that the Acting Under Secretary for Health, in conjunction with 

Veterans Integrated Service Network and VHA facility managers, ensure that: 

• Compliance with VHA regulations regarding CS inspection programs is reinforced. 

• Pharmacies review compliance with USP Chapter <797> guidelines for compounded 

sterile products. 

• Facilities are encouraged to provide guidance for clinical review of polypharmacy in 

high-risk populations, such as mental health patients and the elderly. 

VA Office of Inspector General i 
VA Office of Inspector General 1 

DEPARTMENT OF VETERANS AFFAIRS

Office of Inspector General 

Washington, DC 20420 

TO: Acting Under Secretary for Health (10) 

SUBJECT: Healthcare Inspection – Review of Selected Pharmacy Operations in 

Veterans Health Administration Facilities 

Purpose 

The VA Office of Inspector General (OIG), Office of Healthcare Inspections completed 

an evaluation of select pharmacy processes in Veterans Health Administration (VHA) 

medical facilities. The purpose of our review was to: (1) evaluate pharmacy controls 

related to security and management of controlled substances (CS), (2) determine whether 

medical facilities complied with local and VHA policies regarding pharmacy security and 

handling of CS, and (3) evaluate whether management controls of deterrence and 

detection of CS diversion were effective. 

We evaluated pharmacy internal physical environments, and we assessed whether 

pharmacies had processes to evaluate polypharmacy. We also determined whether 

pharmacies adhered to safety and infection control (IC) standards and whether pharmacy 

clean rooms1

 complied with United States Pharmacopeia (USP) Chapter <797> 

guidelines for clean room construction.2

 

Background 

Controlled Substances 

Based in part on a past report published by the OIG, the Deputy Under Secretary for 

Health for Operations and Management (DUSHOM) identified pharmacy security and CS 

management as material weaknesses.3

 Consequently, the DUSHOM required that 

facilities either conduct a self-assessment of the physical security in pharmacies to 

 

1

 A clean room is where patients’ intravenous medications and solutions are compounded. 2 VHA Handbook 1108.06, Inpatient Pharmacy Services, June 27, 2006. 3 Review of VA Medical Facility Compliance with Controls over Prescription Drugs, Report No. 05-00877-17, 

November 1, 2006. 
Review of Selected Pharmacy Operations in VHA Facilities 

VA Office of Inspector General 2 

safeguard CS or describe progress in meeting previous OIG or System-wide Ongoing 

Assessment and Review Strategy team recommendations.4

 In 2007, the DUSHOM 

required pharmacies to conduct a self-assessment of CS management.5

 This review 

assessed compliance with VHA guidelines for CS inspection programs. 

Infection Control Standards 

The International Organization for Standardization (ISO) classifies a clean room as an 

area where the concentration of airborne particles is controlled. A clean room is 

constructed and used to minimize the introduction, generation, and retention of particles 

inside the room. Temperature, humidity, and pressure in the room should be monitored.6

 

The use of alternative systems, such as a Laminar Airflow Workbench (LAFW)7

 or 

biosafety cabinets8

 that have been verified to achieve an ISO Class 5 environment, may 

be utilized.9

 In 2004, the USP published guidelines for clean rooms, and compliance 

became mandatory on January 1, 2008.10 The guidelines, known as USP Chapter <797>, 

are enforceable through the U.S. Food and Drug Administration. VHA has adopted 

policies that acknowledge the USP as an authority in pharmaceutical practice and 

requires adherence to its guidelines. 

Though packaged medications are rarely contaminated, medication bins, storage areas, or 

the exteriors of individual medication packages can harbor nosocomial pathogens and be 

indirect sources of contamination.11 This review assessed compliance with VHA 

guidelines for cleanliness and safety in day-to-day pharmacy operations.12

Polypharmacy 

Polypharmacy is more complex than just the number of drugs that a patient takes. The 

use of multiple medications is particularly prevalent among the elderly population, 

leading to complex drug regimens and the risk of further complications.13 Although drug 

therapy is often necessary for the maintenance and prevention of disease states, excessive 

 

4

 Deputy Under Secretary for Health for Operations and Management, FY 2006 Monitors and Guidelines. 5

 Deputy Under Secretary for Health for Operations and Management, FY 2007 Monitors and Guidelines. 6

 Department of Veterans Affairs, Office of Facilities Management, Design Alert: Pharmacy Design Compliance 

with U.S. Pharmacopeia chapter <797>, February 23, 2006. 7

 An LAFW is a work area that contains a system of circulating filtered air in parallel flowing planes. The system 

reduces the risk of airborne contamination and exposure in hospital pharmacies. 8

 Ventilated cabinets for personnel and environmental protection that have an un-recirculated inward airflow away 

from the operator that exhausts all air to the atmosphere after filtration through a HEPA filter. 9

 A Class 5 environment is used when a bacteria-free or particulate-free environment is required in the manufacture 

of aseptically produced injectable medicines. 

10 An additional USP Chapter <797> revision bulletin became final on June 1, 2008. 11 Nosocomial infections are infections that are a result of treatment in a hospital or a health care service unit but are 

secondary to the patient's original condition. 

12 VHA Handbook 1108.05, Outpatient Pharmacy Services, May 30, 2006; VHA Handbook 1108.06. 13 Yvette C. Terrie, BS PharmD, RPh, “Understanding and Managing Polypharmacy in the Elderly,” Pharmacy 

Times, December 2004. 
Review of Selected Pharmacy Operations in VHA Facilities 

VA Office of Inspector General 3 

use of medications can result in adverse reactions. Clinically, the criteria utilized for 

identifying polypharmacy involve the following: 

• Taking medications that have no apparent indication. 

• Using therapeutic equivalents to treat the same illness. 

• Concurrently using interacting medications. 

• Using inappropriate dosages. 

• Using additional medications solely to treat adverse drug reactions. 

Polypharmacy in psychiatry is becoming the norm rather than the exception.14 Some 

instances of polypharmacy may not be justifiable, such as when a clinician neglects to 

review medications regularly or to discontinue one antipsychotic medication when

starting another. This review assessed whether facilities had processes to evaluate 

polypharmacy in order to intervene when appropriate. 

Scope and Methodology 

We conducted the review at 43 VHA medical facilities during Combined Assessment 

Program (CAP) reviews conducted from January 1–December 31, 2008. We analyzed 

results and reported deficiencies in each facility CAP review report. 

Our evaluation included reviewing policies and procedures prior to site visits. The 

majority of the review was conducted onsite in the form of tours of the inpatient and 

outpatient pharmacies, pharmacy clean rooms, and CS vaults. We conducted interviews 

with pharmacy staff, CS Coordinators and inspectors, and VA Police personnel. The 

review analyzed pharmacy operations, including environment of care (EOC), IC, 

management of CS, and pharmacy security, and assessed whether pharmacies had 

processes to address polypharmacy. 

We reviewed VHA regulations15 governing pharmacy and CS security, and we assessed 

whether each facility’s policies and practices were consistent with VHA regulations. We 

inspected inpatient and outpatient pharmacies for security, EOC, and IC issues, and we 

interviewed managers from Pharmacy Service and VA Police Service when indicated. 

We reviewed policies and processes to determine whether each facility took action to 

monitor and avoid inappropriate use of multiple medications. In the 43 CAP reports, we 

made 48 recommendations related to pharmacy operations. (See summary on next page.) 

 

14 Vijayalakshmy Patrick, M.D., et al., “Best Practices: An Initiative to Curtail the Use of Antipsychotic 

Polypharmacy in a State Psychiatric Hospital,” Psychiatric Services, 57:21–23, January 2006. 15 VHA Handbook 1108.1, Controlled Substances (Pharmacy Stock), October 4, 2004; VHA Handbook 1108.05; 

VHA Handbook 1108.06. 
Review of Selected Pharmacy Operations in VHA Facilities 

VA Office of Inspector General 4 

We conducted the review in accordance with the Quality Standards for Inspections 

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

Inspection Results 

A. Controlled Substance Inspections 

We determined that 33 (77 percent) of the 43 facilities experienced suspected drug 

diversions during the previous year. All but one facility reported suspected diversions to 

appropriate authorities, including the OIG Office of Investigations. We recommended 

that this one facility’s local policy include internal and external notification procedures. 

We evaluated whether CS inspections were conducted according to VHA regulations.16 

The CS inspection program accounted for 32 (67 percent) of the 48 recommendations. 

CS inspectors at 13 (30 percent) facilities did not conduct inspections in all areas within 

the facility where CS were held. 

Although all CS Coordinators received appropriate training, eight (19 percent) facilities 

lacked documentation that all CS inspectors received annual CS inspection training. In 

addition, at three (7 percent) facilities, the Director did not appoint the CS Coordinator or 

inspectors in writing, as required by VHA policy. The remaining findings included 

findings such as the absence of quarterly reports from CS Coordinators to facility 

Directors and the appointment of an inadequate number of inspectors for the facility’s 

size and CS inspection scope. (See summary on next page.) 

 

16 VHA Handbook 1108.2, Inspection of Controlled Substances, August 29, 2003. 
Review of Selected Pharmacy Operations in VHA Facilities 

VA Office of Inspector General 5 

B. Environment of Care 

Pharmacies were generally clean and adhered to IC guidelines, and only four (9 percent) 

facilities received recommendations in this area. Drug processing areas were free from 

food and drink, floors and sinks were clean, and soap and alcohol-based antibacterial 

hand rubs were readily available. Medication storage areas were designed for maximum 

cleanliness, and medication transport carts were free from spills and liquid medication 

build-up. Pharmacies disposed of personally identifiable patient information in a secure 

manner. We cited four facilities for EOC issues due to cleanliness or inconsistent 

monitoring of temperatures in medication refrigerators. 

Physical Security 

Facilities had appropriate policies and processes to ensure the security of their 

pharmacies and CS. VA Police conducted annual physical assessments of pharmacies, 

identified security weaknesses, and made recommendations when appropriate. We made 

recommendations regarding pharmacy physical security at 2 (5 percent) of the 

43 facilities visited. We recommended installing ballistic glass in a pharmacy outpatient 

prescription-dispensing window and improving security in an outpatient cabinet for CS 

prescriptions awaiting pick-up by patients.17

 

17 VA Handbook 0730/1, Security and Law Enforcement, August 20, 2004.
Review of Selected Pharmacy Operations in VHA Facilities 

VA Office of Inspector General 6 

Controlled Substances Vault Security 

We inspected 45 CS vaults. Generally, vault security complied with VA requirements.18 

All facilities had a process for reviewing vault access by either security access card or 

personnel specific access codes or combinations. Although not a requirement, 

33 (73 percent) of the 45 vaults had a surveillance system in place. However, four vaults 

lacked a steel outer door; two vaults lacked a self-closing day-gate; and one vault lacked 

a steel outer door, a self-closing gate, and an emergency release function. 

C. Infection Control 

Clean Room 

USP Chapter <797>19 describes the procedures and requirements for compounding sterile 

preparations and sets the standards that apply to all settings in which compounded sterile 

products (CSP) are prepared. Clean rooms are commonly utilized to manufacture CSP 

and were developed to mitigate the presence of bacteria and minimize infection rates in 

hospitals. The environment needed to manufacture CSP is influenced by the complexity 

and risk level. Risk levels refer to microbial risk levels and not the hazardous or 

radioactive nature of CSP. USP Chapter <797> requires a minimum of a Class 5 primary 

engineering control, such as an LAFW and/or a biological safety cabinet, to which sterile 

ingredients and components of CSP are directly exposed, regardless of risk level. Via 

self-assessment, pharmacy managers rated the level of compounding at their facility as 

high risk, medium risk, or low risk.20 Of the 43 facilities, 2 manufactured high-risk CSP, 

34 medium-risk, and 7 low-risk. 

Facilities also self-reported on the type of compounding environment in place for the 

manufacture of CSP. Facility self-assessments indicated that 12 (28 percent) utilized a 

Class 5 clean room for sterile compounding. Other methods are acceptable for assuring 

sterility of CSP and include appropriately placed biosafety cabinets and LAFWs. These 

alternate methods were utilized by 31 (72 percent) of the facilities. Of the 12 facilities 

that utilized a clean room, 4 indicated that the clean room was not USP Chapter <797> 

compliant. In order to be compliant, the first facility had construction plans to build a 

new pharmacy, the second planned to remodel the clean room, the third was constructing 

a clean room, and the fourth had resolved an environmental issue to become compliant. 

We identified clean room violations at two facilities. At both facilities, clean room door 

controls were not sufficient to ensure cleanliness of personnel entering the room. At one 

 

18 VA Handbook 0730, Security and Law Enforcement, August 11, 2000; VA Handbook 0730/1. 19 Pharmaceutical Compounding: Sterile Preparations, Chapter <797>, is the first set of enforceable sterile 

compounding standards issued by the USP. 

20 The June 2008 revision of USP Chapter <797> contained changes in assessment of risk levels and added two 

additional risk levels–Immediate-Use Category and Low-Risk Level with <12-hour beyond use date (BUD).
Review of Selected Pharmacy Operations in VHA Facilities 

facility, we also found unsealed ceiling seams, allowing for potential microbial 

accumulation and contamination. 

D. Polypharmacy 

The mentally ill and the elderly are at high risk for polypharmacy. We 

determined whether facilities had policies regarding the identification of polypharmacy 

and whether the policies specifically addressed mental health patients and the elderly. 

Twenty-nine (67 percent) of the 43 facilities had a local policy or procedure that 

addressed assessment of polypharmacy, and 17 (40 percent) had a policy or procedure 

that addressed both high-risk populations. 

Conclusions 

Overall, pharmacies complied with VHA guidelines for IC, pharmacy physical security, 

and reporting requirements; however, improvement in CS inspection programs is 

required to ensure full compliance with VHA regulations. 

Our review was not intended to be an intensive review of clean room and CSP 

compounding environments, but we found variability with progress towards USP 

Chapter <797> compliance. Since USP Chapter <797> revisions were published in 

June 2008, it may be advantageous for facilities to perform a gap analysis and, where the 

need is identified, develop an action plan for compliance. 

Recommendations 

Recommendation 1: We recommended that the Acting Under Secretary for Health 

ensure that Veterans Integrated Service Network (VISN) and VHA facility managers 

reinforce compliance with VHA regulations regarding CS inspection programs. 

Recommendation 2: We recommended that the Acting Under Secretary for Health 

require that VISN and VHA facility managers ensure that pharmacies comply with USP 

Chapter <797> guidelines for CSP. 

Recommendation 3: We recommended that the Acting Under Secretary for Health 

require that VISN and VHA facility managers encourage facilities to provide guidance 

for clinical review of polypharmacy in high-risk populations, such as mental health 

patients and the elderly. 

Acting Under Secretary for Health Comments 

The Acting Under Secretary for Health concurred with the recommendations and 

provided implementation plans. Pharmacy Benefits Management (PBM) staff will assist 

the DUSHOM to reinforce VISN and VHA facility managers’ compliance with VHA 

regulations regarding CS inspection programs. PBM has developed an educational 

VA Office of Inspector General 7 
Review of Selected Pharmacy Operations in VHA Facilities 

VA Office of Inspector General 8 

program for pharmacy personnel on meeting USP Chapter <797> compliance standards. 

VHA provided selected facilities resources for clean room construction. PBM staff will 

help to ensure that VHA and VISN managers are aware of any USP Chapter <797> noncompliance issues and will certify that action plans are in place to address deficiencies. 

Additionally, VHA has provided polypharmacy guidance to facilities for selected highrisk patients in 2008 and 2009. The full text of the comments is shown in Appendix A 

(beginning on page 9). 

Assistant Inspector General for Healthcare Inspections Comments 

The Acting Under Secretary for Health’s comments and implementation plans are 

responsive to the recommendations. We will continue to follow up until all actions are 

complete. 

 (original signed by:)

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

Assistant Inspector General for 

Healthcare Inspections 
Review of Selected Pharmacy Operations in VHA Facilities 

Appendix A 

Acting Under Secretary for Health Comments 

VA Office of Inspector General 9 

Department of 

Veterans Affairs Memorandum

Date: November 6, 2009 

From: Acting Under Secretary for Health (10) 

Subject: OIG Draft Report, Healthcare Inspection – Review of 

Selected Pharmacy Operations, (WebCIMS 441810) 

To: Assistant Inspector General for Healthcare Inspections (54) 

1. I have reviewed the draft report, and I concur with the findings and 

recommendations. I am pleased that the Office of Inspector General found 

that Veterans Health Administration (VHA) pharmacies comply with VHA 

and Infection Control (IC) guidelines, pharmacy physical security, and 

reporting requirements. The report also highlights where additional 

attention is needed overall to comply with the requirements of the 

Controlled Substances (CS) Inspection Programs and to reduce 

variability in compliance with United States Pharmacopeia (USP) 

Chapter <797> guidelines for clean room requirements where compounded 

sterile products are prepared. 

2. VHA’s Pharmacy Benefits Management Services (PBM) has worked to 

provide specific guidance for Facility Directors concerning VHA 

regulations for their oversight of the CS Inspection Programs. Such 

guidance has included web-based training for CS inspectors, which is 

required before and during mandatory annual facility based training. PBM 

also developed an inspection checklist for use by System-wide Ongoing 

Assessment and Review Strategy (SOARS) reviewers. VHA guidance 

provides stricter requirements for managing controlled substances than 

those in the Controlled Substance Act of 1970. PBM staff will work with 

the Office of the Deputy Under Secretary for Health for Operations and 

Management (DUSHOM) to reinforce VISN and VHA facility managers’ 

compliance with VHA regulations regarding CS Inspection Programs. The 

Office of the DUSHOM will request certification from VISN directors that 

all sites are in compliance. 
Review of Selected Pharmacy Operations in VHA Facilities 

VA Office of Inspector General 10 

3. All Department of Veterans Affairs medical centers (VAMCs) that 

perform sterile compounding must comply with USP Chapter <797>. 

Since 2006, VHA’s PBM has regularly provided technical guidance to 

facility pharmacy personnel regarding USP <797> compliance. To ensure 

that VHA and Veterans Integrated Service Network (VISN) managers are 

aware of issues of non-compliance with USP Chapter <797>, PBM 

conducted two surveys for 141 VAMCs (November 2008 and February 

2009) to assess compliance and time-frames for construction of required 

environmentally clean rooms for USP <797> pharmaceutical drug 

compounding. PBM staff will provide technical assistance to the Office of 

the DUSHOM to obtain VISN Directors’ certifications that action plans are 

in place to become compliant with USP Chapter <797>. 

4. While VHA supports the concept of poly-pharmacy reviews for 

high-risk patients, separate reviews are not currently a VHA policy 

requirement. Rather, these types of reviews are expected to be conducted 

in an integrated manner as part of routine medication reconciliation and 

drug therapy management activities. Even so, VHA has provided 

poly-pharmacy guidance to facilities through PBM for selected high-risk 

patients in 2008 and 2009. These activities are expected to continue 

in 2010. 

5. Thank you for the opportunity to review the report and provide 

comments. I would be pleased to discuss any concerns or comments you 

may have about this response. If you have any questions, please have a 

member of your staff contact Margaret Seleski, Director, Management 

Review Service (10B5) at (202) 461-7245. 

(original signed by:) 

Gerald M. Cross, MD, FAAFP 

Attachment 
Review of Selected Pharmacy Operations in VHA Facilities 

VETERANS HEALTH ADMINISTRATION 

Additional Comments Related to Recommendations in OIG Draft 

Report, Healthcare Inspection, Review of Selected Pharmacy 

Operations, WebCIMS441810) 

Date of Report: October 6, 2009 

Recommendations/ Status Completion 

Actions Date 

OIG Recommendations

Recommendation 1: We recommended that the Acting Under Secretary 

for Health ensure that VISN and VHA facility managers reinforce 

compliance with VHA regulations regarding CS Inspection Programs. 

VHA Comments

Concur 

Pharmacy Benefits Management staff will assist the office of the Deputy 

Under Secretary for Health for Operations and Management (DUSHOM) to 

reinforce VISN and VHA facility managers’ compliance with VHA 

regulations regarding CS Inspection Programs. The DUSHOM office will 

request certification from VISN directors that all sites are in compliance. 

In process December 30, 2009 

Recommendation 2: We recommended that the Acting Under Secretary 

for Health require that VISN and VHA facility managers ensure that 

pharmacies comply with USP Chapter <797> guidelines for CSP. 

VHA Comments

Concur 

All Department of Veterans Affairs medical centers (VAMCs) that 

perform sterile compounding must comply with USP Chapter <797>. 

In 2006, Pharmacy Benefits Management Services (PBM) developed a 

USP <797> Educational Program in video format for use by VHA 

pharmacy service personnel on competency training modules to meet 

USP <797> compliance standards. Since 2006, PBM has regularly 

provided technical guidance to facility pharmacy personnel regarding 

VA Office of Inspector General 11 
Review of Selected Pharmacy Operations in VHA Facilities 

USP <797> compliance. This guidance is also located on PBM’s website 

in the form of Frequently Asked Questions (FAQs) and technical guidance 

documents. 

Additionally, in 2006 and 2008, PBM and the VA Office of Construction 

and Facilities Management (OCFM) jointly published a Pharmacy Design 

Guidance document on various options and approaches for construction of 

mechanical and architectural systems related to both the Controlled 

Substance Program (CSP) and hazardous drugs. VAMC facilities were also 

provided resources by PBM and OCFM to select suitable vendors for clean 

room construction. 

The USP published new USP Chapter <797> revisions that were finalized 

in December 2007 with a provision that The Joint Commission will expect 

hospitals to have at least an action plan with time-lines to ensure structures 

and processes are in place to conduct safe practices for CSPs. These 

revised standards were disseminated by PBM to VAMCs. PBM conducted 

two surveys for 141 VAMCs (November 2008 and February 2009) 

through the VISN network offices to assess compliance and timeframes 

for construction of required environmentally clean rooms for USP 

Chapter <797> pharmaceutical drug compounding. 

Pharmacy Benefits Management staff will provide technical assistance to 

the office of the DUSHOM to ensure that VHA and VISN managers are 

aware of non-compliance issues with United States Pharmacopeia (USP) 

Chapter <797> as indicated by the survey results, and certify they have 

action plans in place to become compliant with the requirements. 

In process November 2009 to notify VISN 

and Facility managers; July 2011 

for full compliance with USP 

Chapter <797> 

Recommendation 3: We recommended that the Acting Under Secretary 

for Health require that VISN and VHA facility managers encourage 

facilities to provide guidance for clinical review of polypharmacy in 

high-risk populations, such as mental health patients and the elderly. 

VHA Comments

Concur 

While VHA supports the concept of poly-pharmacy reviews for high-risk 

patients, separate reviews as recommended in the report are not currently a 

VA Office of Inspector General 12 
Review of Selected Pharmacy Operations in VHA Facilities 

VA Office of Inspector General 13 

VHA policy requirement. Rather, these types of reviews are expected to be 

conducted in an integrated manner as part of routine medication 

reconciliation and drug therapy management activities. 

Despite there not being an existing VHA policy requirement, VHA has 

provided poly-pharmacy guidance to facilities through its Pharmacy 

Benefits Management Services group. This was done for selected high-risk 

patients in 2008 and 2009 and is expected to continue in 2010. 

Completed 2008 and 2009 Ongoing 

Veterans Health Administration 

November 2009 
Review of Selected Pharmacy Operations in VHA Facilities 

Appendix B 

OIG Contact and Staff Acknowledgments 

OIG Contact Jeanne Martin, PharmD 

Bedford Regional Office of Healthcare Inspections 

(603) 222-5872

Acknowledgments Annette Acosta 

Daisy Arugay 

Gail Bozzelli 

Shirley Carlile 

Paula Chapman 

Victoria Coates 

Audrey Collins-Mack 

Melanie Cool 

Dorothy Duncan 

David Griffith 

Wachita Haywood 

Katherine Owens 

Reba Ransom 

Wilma Reyes 

Annette Robinson 

Christa Sisterhen 

Virginia Solana 

Toni Woodard 

VA Office of Inspector General 14 
Review of Selected Pharmacy Operations in VHA Facilities 

Appendix C 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

Office of General Counsel 

Veterans Integrated Service Network Directors (1–23) 

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 

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

VA Office of Inspector General 15