Department of Veterans Affairs 

Office of Inspector General 

Healthcare Inspection 

Community Based Outpatient 

Clinic Reviews 

Cambridge and Fort Howard, MD 

Alexandria, VA and Greenbelt, MD 

Wilmington and Jacksonville, NC 

Report No. 09-01446-233 September 30, 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: Cambridge and Fort Howard, Alexandria and Greenbelt, Wilmington and Jacksonville 

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 5, VA Maryland HCS – Cambridge and Fort Howard.................................. 6 

B. VISN 5, Washington DC VAMC – Alexandria and Greenbelt ............................... 8 

C. VISN 6, Fayetteville VAMC – Wilmington and Jacksonville............................... 14 

Appendixes

A. VISN 5 Director Comments................................................................................... 21 

B. VA Maryland HCS Director Comments ................................................................ 22 

C. Washington DC VAMC Director Comments ........................................................ 23 

D. VISN 6 Director Comments................................................................................... 26 

E. Fayetteville VAMC Director Comments................................................................ 27 

F. CBOC Characteristics............................................................................................. 31 

G. Quality of Care Measures – Cambridge and Fort Howard .................................... 33 

H. Quality of Care Measures – Alexandria and Greenbelt ......................................... 35 

I. Quality of Care Measures – Wilmington and Jacksonville..................................... 37 

J. OIG Contact and Staff Acknowledgments.............................................................. 39

K. Report Distribution................................................................................................. 40 

VA Office of Inspector General 
CBOC Reviews: Cambridge and Fort Howard, Alexandria and Greenbelt, Wilmington and Jacksonville 

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 six CBOCs during 

the week of August 10–14, 2009. The CBOCs reviewed in Veterans Integrated Service 

Network (VISN 5) were Cambridge and Fort Howard, MD; and Alexandria, VA and 

Greenbelt, MD, and, in VISN 6, Wilmington and Jacksonville, NC. The parent facilities 

of these CBOCs are VA Maryland Healthcare System (HCS), Washington DC VA 

Medical Center (VAMC), and Fayetteville 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 5 and 6, in conjunction with the respective facility manager, should take 

appropriate actions on the following recommendations: 

• Require that physician privileges are appropriate to the procedures performed. 

• Utilize performance improvement data during the reprivileging process. 

• Consistently monitor collaborative practice of physician assistants. 

• Maintain patients’ auditory privacy during their check-in process. 

• Apply appropriate protective screens to computer monitors. 

• Determine the appropriateness of an internal panic alarm system. 

• Install the approved panic alarm system. 

• Properly identify the locations of all fire extinguishers. 

• Revise standard operating procedures to reflect the current practices for medical 

emergencies and to include intervention for disruptive and violent behavior. 

• Implement processes to secure and protect personally identifiable information. 

• Examine the existing medication management processes to ensure quality and 

safety standards are met when dispensing the outpatient medications. 

VA Office of Inspector General i 
CBOC Reviews: Cambridge and Fort Howard, Alexandria and Greenbelt, Wilmington and Jacksonville 

VA Office of Inspector General ii 

• Provide proper CBOC access to disabled patients. 

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

and conditions. 

• Take steps to recover overcharges on billings for enrollees who have not received 

services in the prior 12 months. 

Comments 

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

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

pages 21–30, for the full text of the Directors’ comments.) We will follow up on the 

planned actions until they are completed. 

 (orignal signed by:)

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

Assistant Inspector General for 

Healthcare Inspections 
CBOC Reviews: Cambridge and Fort Howard, Alexandria and Greenbelt, Wilmington and Jacksonville 

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) and Vet 

Centers. 

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 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: Cambridge and Fort Howard, Alexandria and Greenbelt, Wilmington and Jacksonville 

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 the 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, 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: Cambridge and Fort Howard, Alexandria and Greenbelt, Wilmington and Jacksonville 

Part II. CBOC Characteristics 

Veterans Integrated Service Network (VISN) 5 has 4 VHA hospitals and 15 CBOCs, and 

VISN 6 has 8 VHA hospitals and 27 CBOCs. As part of our review, we inspected 

6 CBOCs (5 VA leased and 1 contracted). The CBOCs reviewed were Cambridge and 

Fort Howard, MD; Alexandria, VA and Greenbelt, MD; and Wilmington and 

Jacksonville, NC. The parent facilities of these CBOCs are VA Maryland Healthcare 

System (HCS), Washington DC VA Medical Center (VAMC), and Fayetteville 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 CBOCs was 4,189 

(range 1,435 to 7,234). Figure 1 shows characteristics of the 6 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 

5 Cambridge, MD Baltimore, MD VA Staffed Rural 6.9 4,812 19,020 

5 Fort Howard, MD Baltimore, MD VA Staffed Urban 4.3 7,234 17,135 

5 Alexandria, VA Washington, DC VA Staffed Urban 3.5 2,195 6,444 

5 Greenbelt, MD Washington, DC VA Staffed Urban 2.55 1,435 5,837 

6 Wilmington, NC Fayetteville, NC Contract Urban 5.0 6,806 20,990 

6 Jacksonville, NC Fayetteville, NC VA Staffed Urban 3.0 2,652 9,136 

Figure 1 - CBOC Characteristics, FY 2008 

Two out of the six CBOCs provide Specialty Care services onsite (Cambridge and Fort 

Howard), while the other four CBOCs refer patients to the parent facility. Cambridge 

provides occupational therapy, optometry, urology, and women’s health. Fort Howard 

provides podiatry and rheumatology. 

All six CBOCs have laboratory services and provide electrocardiograms (EKGs) onsite. 

Two of the six are able to provide basic blood tests onsite (Alexandria and Greenbelt). 

Veterans have access to social services at four CBOCs. Four CBOCs provide onsite 

dietary services. Three of the six CBOCs provide tele-medicine. 

All six CBOCs provide MH services onsite. The type of provider varied among the 

CBOCs to include primary care physicians, psychologists, psychiatrists, nurse 

practioners, social workers, and addiction counselors. Tele-mental health is available at 

two CBOCs. Four CBOCs report that MH services are provided 5 days a week 

(Cambridge, Fort Howard, Wilmington, and Jacksonville); one CBOC provides MH 

2 days per week, including 2 Saturdays per month (Alexandria); and one CBOC provides 

VA Office of Inspector General 3 
CBOC Reviews: Cambridge and Fort Howard, Alexandria and Greenbelt, Wilmington and Jacksonville 

MH 38 hours per week (Greenbelt). Additional CBOC characteristics are listed in 

Appendix F.

VA Office of Inspector General 4 
CBOC Reviews: Cambridge and Fort Howard, Alexandria and Greenbelt, Wilmington and Jacksonville 

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 

diabetes, 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 all CBOC providers’ C&P files 

and all 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 one CBOC contract (Wilmington) 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: Cambridge and Fort Howard, Alexandria and Greenbelt, Wilmington and Jacksonville 

Part IV. Results and Recommendations 

A. VISN 5, VA Maryland HCS – Cambridge and Fort Howard 

Quality of Care Measures 

The Cambridge CBOC scores were higher than the parent facility for all measures. The 

Fort Howard CBOC scores were higher than the parent facility on diabetes mellitus (DM) 

foot inspection and pedal pulses and PTSD screening. The Fort Howard CBOC scored 

lower than the parent facility on hyperlipidemia, foot sensory exam, and renal testing. 

(See Appendix G.) 

Credentialing and Privileging 

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

both the Cambridge and Fort Howard CBOCs. All providers and nurses possessed a full, 

active, current, and unrestricted license. C&P files and nurses’ personnel folders were 

well organized and contained the required documentation. 

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 clean and well 

maintained. The CBOCs met all standards, and the environment was clean and safe. 

Emergency Management

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

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

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

local emergency response guidelines. 

VA Office of Inspector General 6 
CBOC Reviews: Cambridge and Fort Howard, Alexandria and Greenbelt, Wilmington and Jacksonville 

Patient Satisfaction 

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

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) 

512 Maryland HCS Mean 

Score 

69.8 79.8 70.2 80 78.5 

N= 56 55 61 1,153 54,400 

512GA Cambridge 77 88.1 89.1 

 N= 75 71 74 

512GF Fort Howard 88 79.6 72.2 

N= 56 77 67 

Figure 2. Outpatient Overall Quality 

Both CBOCs scored equal or higher in “outpatient overall quality” than the parent facility 

in FY 2008. Both CBOCs met VHA target score of 77 with the exception of Fort 

Howard in the 2nd Qtr. 

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) 

512 Maryland HCS Mean 

Score 

62.2 69.8 72.1 72.9 77.3 

 N= 59 55 64 1,164 55,407 

512GA Cambridge 82.2 83 85.2 

 N= 76 70 76 

512GF Fort Howard 79.8 69.5 85.4 

N= 57 81 67 

Figure 3. Provider Wait Times 

The parent facility failed to meet the VHA target score of 77 in FY 2008; however, both 

CBOCs met the VHA goal with the exception of Fort Howard in the 3rd Qtr. Fort 

Howard CBOC was able to improve “provider wait times” by 10 percent by the 4th Qtr. 

The Cambridge and Fort Howard CBOCs were in compliance with local and VHA 

policies. We made no recommendations. 

VA Office of Inspector General 7 
CBOC Reviews: Cambridge and Fort Howard, Alexandria and Greenbelt, Wilmington and Jacksonville 

VA Office of Inspector General 8 

B. VISN 5, Washington DC VAMC – Alexandria and Greenbelt 

Quality of Care Measures 

Both CBOCs equaled or exceeded the parent facility with the following exceptions. 

Greenbelt scored less than the parent facility on the DM retinal assessment and the foot 

inspection measures. Alexandria scored less than the parent facility on the DM foot 

inspection, pedal pulse evaluation, and foot sensory exam measures. (See Appendix H.) 

Credentialing and Privileging 

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

the Greenbelt CBOC and five providers and three nurses at the Alexandria CBOC. All 

providers possessed a full, active, current, and unrestricted license. All nursing licenses 

and educational requirements were verified and documented. We identified the following 

areas that needed improvement: 

Privileging

We found that the medical center’s Professional Standards Board (PSB) had granted 

clinical privileges to physicians at both CBOCs; however, these privileges were granted 

without documented evidence that the physician was competent to perform the 

procedures. Additionally, some procedures (lumbar puncture, paracentesis, and 

thoracentesis) were not provided or performed at either CBOC. According to VHA 

Handbook 1100.19, all health care professionals who are permitted by law and the 

facility to provide patient care services independently must be credentialed and 

privileged, and only privileges for procedures actually provided by the VA facility may 

be granted to a practitioner. 

Performance Improvement

Neither CBOC utilized Performance Improvement (PI) provider-specific data in the 

reprivileging process. VHA Handbook 1100.19 requires that provider-specific PI data be 

used to determine if the provider is competent to perform the privileges being sought 

during the reprivileging process. 

Declaration of Health

The medical center obtained the health declarations of Licensed Independent 

Practitioners (LIPs) during the reappraisal process as required by VHA Handbook 

1100.19, but failed to scan the declarations into the VetPro system3

 as required. Failure 

to scan these documents into the VetPro system has the potential of decreasing the 

 

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: Cambridge and Fort Howard, Alexandria and Greenbelt, Wilmington and Jacksonville 

VA Office of Inspector General 9 

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. 

Recommendation 1. We recommended that the VISN 5 Director ensure that the 

Washington DC VAMC Director requires physician privileges are appropriate to the 

procedures performed at each CBOC. 

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

Privileging procedures have been revised and sent for approval to the Chief of Medicine 

Service. 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 5 Director ensure that the 

Washington DC VAMC Director requires both CBOCs to utilize PI data during the 

reprivileging process. 

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

data has been incorporated into the quarterly provider reviews with the inclusion of three 

new indicators. 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 met most standards, and the 

environments were generally clean and safe with the following exceptions that needed 

improvement: 

Personally Identifiable Information 

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

process at the Alexandria and the Greenbelt CBOCs. VHA Handbook 1605.14

 requires 

auditory privacy when staff discuss sensitive patient issues. At both CBOCs, patients 

communicate with staff through a slide-open glass window located in the waiting area. 

Patients are asked to provide, at a minimum, their name and full social security number 

(SSN). There were no instructions to incoming patients to allow patients at the window a 

zone of audible privacy during the check-in process. 

 

4

 VHA Handbook 1605.1, Privacy and Release of Information, May 17, 2006. 
CBOC Reviews: Cambridge and Fort Howard, Alexandria and Greenbelt, Wilmington and Jacksonville 

Patient Records. According to Health Insurance Portability and Accountability Act 

(HIPAA) regulations, control of the environment includes control of confidential patient 

information. At the Greenbelt CBOC, we found a patient’s personally identifiable 

information (PII) could potentially be accessed by patients or visitors. During our tour, 

we observed the following: 

• A patient intake data form that contained patient health information, the patient’s 

name, and the patient’s SSN was placed on an unsecured wall shelf outside an 

exam room. Although protective folders were readily available for staff to utilize, 

the form was not placed in such a folder. While PII was not visible, the placement 

of the document allowed passersby to view other information on the document. 

Additionally, staff were not in the immediate area to assure this information was 

secure. 

• Computer monitors were equipped with protective screen covers; however, they 

were ineffective. While standing in a common hallway, we were able to easily 

view a patient’s name, address, and telephone number. 

Panic Alarms 

Both CBOCs provide MH services, but neither has an internal panic alarm system to alert 

other staff if they need assistance with a disruptive/violent patient. The clinical staff 

indicated they would call out for help, dial 911, or have the administrative staff activate 

the external panic alarm if they felt threatened and needed assistance. Both CBOCs had 

external panic alarms located at the check-in desk. These alarms activated the local 

emergency response system (police, fire department, and ambulance). Staff reported that 

the emergency response time was approximately 3–4 minutes. 

In 2007, the Washington DC VA police conducted a security alarm evaluation at the 

Alexandria CBOC to assess the need of installing a security system. The VA police 

recommended that panic alarms be installed in “all office areas where staff/patient 

consults are conducted.” The recommendation was approved by the Acting Medical 

Center Associate Director (November 1, 2007). However, no action for the installation 

of panic alarms had been implemented at the time of our inspection. 

Fire Extinguishers 

The National Fire Protection Association Life Safety Code requires signage identifying 

the location of fire extinguishers. During the Greenbelt CBOC environmental tour, we 

noted one of two available fire extinguishers was located inside an ancillary room. There 

was no signage to alert staff or rescue personnel of the fire extinguisher’s location. 

Recommendation 3. We recommended that the VISN 5 Director ensure that the 

Washington DC VAMC Director requires auditory privacy be maintained during the 

check-in at both Alexandria and Greenbelt CBOCs. 

VA Office of Inspector General 10 
CBOC Reviews: Cambridge and Fort Howard, Alexandria and Greenbelt, Wilmington and Jacksonville 

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

Respect patient privacy signage has been posted at the reception desks. A physical 

separation of queue from patient intake has been created. The improvement plans are 

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

Recommendation 4. We recommended that the VISN 5 Director ensure that the 

Washington DC VAMC Director requires appropriate protective screens be applied to the 

monitors at the Greenbelt CBOC. 

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

Privacy screens have been added to monitors at the Grenbelt CBOC. The improvement 

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

completed. 

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

Washington DC VAMC Director determines the appropriateness of an internal panic 

alarm system at both Alexandria and Greenbelt CBOCs. 

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

Police/Security are conducting an evaluation for internal panic alarm options. 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 5 Director ensure that the 

Washington DC VAMC Director requires that the locations of all fire extinguishers are 

properly identified at the Greenbelt CBOC. 

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

assessment has been completed, and signage has been ordered. 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 emergencies, including MH, are handled. Neither CBOC had a SOP developed 

for the management of medical and MH emergencies prior to July 2009. The SOP 

described the purpose of the medical emergency plan as “entails the procedures the 

CBOC staff takes in case of medical emergencies (cardiac arrest, seizures, etc.).” The 

plan described what events/conditions would promote staff to activate 911. The medical 

emergency SOP did not include: 

VA Office of Inspector General 11 
CBOC Reviews: Cambridge and Fort Howard, Alexandria and Greenbelt, Wilmington and Jacksonville 

VA Office of Inspector General 12 

• The use of an automated external defibrillator (AED) in the management of 

cardiac arrest at the CBOCs as required by VHA Directive 2008-015.5

 

• Medical management of seizures or severe hypoglycemia other than activating 

911. 

When questioned, staff at both CBOCs indicated they would give oral glucose to a 

patient to elevate the patient’s blood sugar (hypoglycemia). However, we found 

Dextrose 50 (D50)6

 and intravenous (IV) fluids at the Greenbelt CBOC. Nursing staff 

stated they would administer D50 if instructed by a provider, but the emergency 

personnel would probably arrive before they could insert an IV line. 

Both CBOCs had an SOP to address patients who present with suicidal behavior to the 

CBOCs, but management of disruptive and/or violent behavior was addressed in the 

parent facility’s local policy.7

 The parent facility policy directs staff to call “7-BUY,” 

which is the Washington DC VAMC police emergency line. This is not a viable option 

for either CBOC as they are not connected to the medical center’s phone system or 

located within a close proximity of the parent facility. 

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

Washington DC VAMC Director requires both Alexandria and Greenbelt CBOCs revise 

the local SOP for medical emergencies to reflect the current practices and revise the 

mental health SOP to include intervention for disruptive and violent behavior. 

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

have been revised to include medical and psychiatric emergencies as well as appropriate 

interventions for disruptive/violent behaviors. 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. 

 

5

 VHA Directive 2008-015, Public Access to Automated External Defibrillators (AEDs): Deployment, Training, and 

Policies for Use in VHA Facilities, March 12, 2008. 6

 High-dose sugar solution given intravenous to elevate low blood sugar. 

7

 Medical Center Policy Memorandum No. 116A-10, Prevention and Management of Disruptive and Violent 

Behavior, January 2009. 
CBOC Reviews: Cambridge and Fort Howard, Alexandria and Greenbelt, Wilmington and Jacksonville 

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) 

688 Washington DC 

VAMC 

Mean 

Score 

74.6 84.2 70.6 80 78.5 

N= 42 55 48 1,153 54,400 

688GA Alexandria 93.4 86.9 86.2 

 N= 55 69 47 

688GC Greenbelt 82.9 85.7 81 

N= 50 63 41 

Figure 4. Outpatient Overall Quality 

Both CBOCs exceeded the parent facility’s “overall quality” indicator and far exceeded 

the VHA target goal of 77. 

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) 

688 Washington DC 

VAMC 

Mean 

Score 

65.2 69.3 70.7 72.9 77.3 

 N= 

42 55 48 1164 55,407 

688GA Alexandria 94.2 87.9 92.9 

 N= 56 69 46 

688GC Greenbelt 91.8 95 93.7 

N= 47 62 44 

Figure 5. Provider Wait Times 

Both CBOCs exceeded the parent facility’s “provider wait times” SHEP scores. The 

parent facility scored below the VHA target goal of 77 while both CBOCs scored well 

above the goal. 

VA Office of Inspector General 13 
CBOC Reviews: Cambridge and Fort Howard, Alexandria and Greenbelt, Wilmington and Jacksonville 

VA Office of Inspector General 14 

C. VISN 6, Fayetteville VAMC – Wilmington and Jacksonville 

Quality of Care Measures 

The Jacksonville and Wilmington CBOCs scored lower than the parent facility in the 

following quality measure scores: DM foot inspection, foot pedal pulse evaluation, foot 

sensory exam, and renal testing. Jacksonville CBOC’s renal testing score of 67 percent 

was far below the 93 percent target goal. Wilmington scored 83 percent on the DM 

retinal eye exam and LDL-C, which are below the target goal of 88 and 95, respectively. 

The CBOCs have undergone some staff turnover, to include the Wilmington CBOC 

transitioning from contract to VA staff, which has impacted on the continuity of services. 

Senior management anticipates that the quality measure results will improve with the 

stabilization of staff. (See Appendix I.) 

Credentialing and Privileging 

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

the Jacksonville CBOC and reviewed the files of four providers and four nurses at the 

Wilmington CBOC. All providers possessed a full, active, current, and unrestricted 

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

Clinical Privileges 

The PSB had granted providers clinical privileges for procedures that were not performed 

at the CBOCs. For example, two primary care physicians were granted privileges to 

perform thoracenthesis and mechanical ventilation. VHA Handbook 1100.19 requires 

clinical privileges be granted based on the needs of the facility. 

Monitoring of Physician Assistants 

VHA policy8

 requires that each clinical service chief ensures physician assistants’ (PAs’) 

clinical activities are monitored and evaluated. We found inconsistencies in the 

performance monitoring of a PA at the Wilmington CBOC. We reviewed the C&P file of 

the PA and did not find evidence that performance was monitored consistently by the 

designated collaborating physician identified in the PA’s Scope of Practice.9

 

Recommendation 8. We recommended that the VISN 6 Director ensure that the 

Fayetteville VAMC Director requires that PSB grant privileges consistent with the 

services provided at both Wilmington and Jacksonville CBOCs. 

 

8

 VHA Directive 2004-029, Utilization of Physician Assistants, July 2, 2004. 9

 “Scope of practice” is a term used to describe activities that may be performed by health care workers, regardless 

of whether they are licensed independent healthcare providers. The scope of practice is specific to the individual 

and the facility involved. 
CBOC Reviews: Cambridge and Fort Howard, Alexandria and Greenbelt, Wilmington and Jacksonville 

VA Office of Inspector General 15 

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

privileges have been reviewed by the Chief, Primary Care Services. Adjustment to 

current privileges will be completed at the next scheduled PSB meeting. The 

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

they are completed. 

Recommendation 9. We recommended that the VISN 6 Director ensure that the 

Fayetteville VAMC Director requires consistent monitoring of collaborative practice at 

the Wilmington CBOC. 

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

Monthly medical record reviews will be conducted, and the results will be reported to the 

Chief of Primary Care Service. 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 most standards, and the environments 

were generally clean and safe. However, we found the following areas that needed 

improvement: 

Personally Identifiable Information 

According to HIPAA regulations, control of the environment includes control of PII. At 

the Wilmington CBOC, we found clinic lists dated August 5–7, 2009, with patients’ 

names and SSNs. We found patient diagnostic information written on slips of paper in an 

unsecured physician’s and nurse’s office space. We also found a completed Percocet®

prescription unsecured in a physician’s office. The CBOC manager told us the majority 

of staff were newly hired to the VA system and needed additional privacy training. 

Medication Safety 

The Jacksonville and Wilmington CBOCs had a stock of medications for onsite clinical 

intervention that included antibiotics and injectables such as atropine, epinephrine, and 

Solu-Medrol®. According to the local emergency management policies, if a patient 

requires an urgent clinical treatment, the provider can order medications from the stock 

supply located in the clinic. The providers place medication orders through the pharmacy 

package of the computerized physician order entry (CPOE) or nursing text orders.10 

CPOE software provides clinical information such as allergies, unusual dosages, and 

drug-to-drug interactions. We found that some providers were circumventing this 

 

10 Electronic order written to nursing staff by the LIP. Nursing text orders are not part of the pharmacy package. 
CBOC Reviews: Cambridge and Fort Howard, Alexandria and Greenbelt, Wilmington and Jacksonville 

VA Office of Inspector General 16 

process by utilizing the nursing text orders feature. This practice excludes the Pharmacy 

Service from the medication management review process and bypasses the automated 

patient safety features of CPOE. CBOC managers could not tell us how many 

medication orders were placed utilizing nursing text orders. VHA policy11 refers to the 

use of CPOE as a resource available to improve medication safety. 

Panic Alarms 

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

utilized to ensure a safe environment and a rapid response to a mental health emergency. 

Although the Wilmington CBOC did not have panic alarm system, the parent facility had 

identified the need prior to our visit and informed us they plan to install a system in 

6 weeks. 

Handicap Access 

Ramps to the front doors of both clinics allowed patients in wheelchairs or with other 

assistive devices to independently maneuver to the clinic door. In the Jacksonville 

CBOC, there was a handicap assist button to open the clinic door; however, the button 

was non-functional. Additionally, the standard size door could impede the entrance of 

patients or visitors in an electric wheelchair. 

Recommendation 10. We recommended that the VISN 6 Director ensure that the 

Fayetteville VAMC Director requires that processes be implemented to secure and 

protect personally identifiable information at the Wilmington CBOC. 

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

privacy training is scheduled, and the effectiveness of the training will be measured 

through random rounds conducted by the Clinic Nurse Manager. 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 6 Director ensure that the 

Fayetteville VAMC Director examines the existing medication management processes to 

ensure quality and safety standards are met when dispensing the outpatient medications at 

both Wilmington and Jacksonville CBOCs. 

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

CBOC providers have been instructed to use the CPOE. A random sample of 10 orders 

per month per CBOC will be reviewed and reported to the Primary Care Service Line. 

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

until they are completed. 

 

11 VHA Handbook 1108.05, Outpatient Pharmacy Services Veterans Health Administration Transmittal Sheet, 

May 30, 2006. 
CBOC Reviews: Cambridge and Fort Howard, Alexandria and Greenbelt, Wilmington and Jacksonville 

Recommendation 12. We recommended that the VISN 6 Director ensure that the 

Fayetteville VAMC Director requires a panic alarm system is installed at the Wilmington 

CBOC. 

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

panic alarm system is being installed at the Wilmington CBOC. 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 6 Director ensure that the 

Fayetteville VAMC Director requires that patients in wheelchairs or with other assistive 

devices have proper access to the Jacksonville CBOC. 

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

handicap assist buttons should soon be operational. 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 emergencies (including MH) 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. 

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) 

565 Fayetteville 

VAMC 

Mean 

Score 

57.8 65.8 45.7 71.3 78.5 

N= 67 68 66 1,689 54,400 

565GC Wilmington 49.4 57.5 64.2 

N= 68 57 70 

565GA Jacksonville 54.9 66.8 70.1 

N= 54 56 68 

Figure 6. Outpatient Overall Quality 

VA Office of Inspector General 17 
CBOC Reviews: Cambridge and Fort Howard, Alexandria and Greenbelt, Wilmington and Jacksonville 

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) 

565 Fayetteville VAMC Mean 

Score 

74.6 70.6 73.2 76 77.3 

 N= 71 66 64 1,703 55,407 

565GC Wilmington 70.7 65.9 72.6 

N= 69 58 68 

565GA Jacksonville 76.1 85.8 83.6 

N= 59 57 69 

Figure 7. Provider Wait Times 

The parent facility and Wilmington CBOC failed to meet the target measure of 77 for 

“outpatient overall quality” and “provider wait times.” The Jacksonville CBOC failed 

“overall quality” for FY 2008; however, it exceeded “provider wait times” measures in 

the 2nd and 3rd Qtrs. The Jacksonville CBOC exceeded the target measure on the 2nd and 

3rd quarters but failed to meet the target for the 4th Qtr for the “provider wait times.” 

According to the management staff interviewed, there have been several endeavors 

launched to improve the patients’ perception of clinical services at the CBOCs. These 

efforts included staff training on customer service, establishing a group orientation 

program for all patients, and developing a “quick cards” system that provides concurrent 

feedback of patients’ perceptions. These processes enabled staff to address patient 

dissatisfaction prior to the patient leaving the CBOC. The results of these efforts have 

shown improvement in the recent patient satisfaction scores. 

CBOC Contract 

Wilmington CBOC 

The contract for the Wilmington CBOC is administered through the Fayetteville VAMC 

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

care for all eligible veterans in VISN 6. Contracted services with Magnum Medical Joint 

Venture (Magnum) began on November 28, 2005, with option years extending through 

November 27, 2008. Their current contract was administered under a 6-month contract 

extension for the period December 1, 2008, through May 31, 2009. A VA operated and 

staffed clinic was established effective June 1, 2009. The contract terms state that the 

CBOC will have (1) a North Carolina licensed physician to serve as medical director and 

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

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

VA Office of Inspector General 18 
CBOC Reviews: Cambridge and Fort Howard, Alexandria and Greenbelt, Wilmington and Jacksonville 

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

CBOC had 6,806 unique primary medical care enrollees with 20,990 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 

Fayetteville 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 format of the invoices was not in accordance with the contract provisions in 

section G, “Rates and Payments,” bullet (b). This provision states that the invoice 

will have the following three separate categories: (1) patients on prior month’s 

invoice, (2) newly enrolled patients since the previous month’s invoice, and 

(3) disenrolled since the previous month’s invoice. Magnum’s invoices reported 

only a total of enrolled patients based on a list of enrollees provided by the VAMC. 

Magnum incorporated the VAMC prepared list of enrollees as part of the invoice. 

This list prepared by VAMC and provided to the contractor was compared to the list 

of patients from the Veterans Health Information Systems and Technology 

Architecture (VistA) seen by the CBOC within the last year. There were issues with 

this list that are discussed below. 

B. We noted that 642 out of 6,871 enrollees reported on Magnum’s December 2008 

invoice had not received any services in the prior 12 months. Monthly, the VAMC 

generated enrollee data which became the basis for Magnum’s invoices. That 

enrollee data was based upon patients assigned to a panel for 24 months and does 

not account for veterans who did not receive an annual “qualifying visit” as cited in 

the contract. 

The contract specifically states under the provisions, Clinical Procedures and 

Requirements, section (A) Primary Care, bullet (e), that each CBOC patient will 

have at least one qualifying visit annually. Additionally, if the enrollee did not 

receive a qualifying visit, then the VAMC must be provided with documentation of 

the CBOC’s attempts to contact the patient at the end of each fiscal year. 

Analytical tests were performed to determine the contractor’s compliance with 

contractual terms regarding billing of enrollees based upon services received at the 

clinic. We noted the following: 

• The list of 6,871 enrollees billed on the December 2008 invoice was 

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

VA Office of Inspector General 19 
CBOC Reviews: Cambridge and Fort Howard, Alexandria and Greenbelt, Wilmington and Jacksonville 

VA Office of Inspector General 20 

• The tests resulted in identifying 642 enrollees billed to the VA who had not 

received any services at the CBOC for the period January 1, 2008, through 

December 31, 2008. 

C. We noted that 75 out of 6,871 enrollees reported on the December 2008 invoice had 

“last appointment dates” ranging from February 2005 to November 2006. These 

75 enrollees should have been considered as inactive and disenrolled in accordance 

with the 24-month parameters cited in VHA Handbook 1101.02,12 paragraph 12. 

D. The contract required that the contractor notify VAMC regarding patients who do 

not respond to disenrollment notifications or were “No Shows” for two consecutive 

appointments.13 There was no evidence that this notification took place. 

E. The contract required that the contractor notify VAMC annually regarding patients 

who do not receive any annual “qualifying visit.”14 There was no evidence that this 

notification took place. 

By not adhering to these provisions in the contract, VAMC could be overpaying the 

contractor for these services. 

Recommendation 14. We recommended that the VISN 6 Director ensure that 

Fayetteville VAMC Director provides contract oversight and enforcement in accordance 

with the terms and conditions as stated in the contract for the Wilmington CBOC. 

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

contract with Magnum Joint Venture/Sterling Medical was not renewed. 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 6 Director ensure that the 

Fayetteville VAMC Director takes steps to recover overcharges on billings for 

Wilmington CBOC enrollees who have not received services in the prior 12 months. 

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

are underway to initiate a bill of collection to the former contractor. The improvement 

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

completed. 

 

12 VHA Handbook 1101.02, Primary Care Management Module, April 21, 2009. 13 See Contract provision: (3) Clinical Procedures and Requirements (I) Enrollment and Dis-enrollment of Patients 

(5) l and (6). 

14 See Contract provision: (3) Clinical Procedures and Requirements (A) Primary Care (e). 
CBOC Reviews: Cambridge and Fort Howard, Alexandria and Greenbelt, Wilmington and Jacksonville 

Appendix A 

VISN 5 Director Comments 

VA Office of Inspector General 21 

Department of 

Veterans Affairs Memorandum

Date: September 15, 2009 

From: Director, VISN 5 (10N5) 

Subject: Healthcare Inspection – CBOC Reviews: Cambridge and 

Fort Howard, MD; Alexandria, VA; and Greenbelt, MD

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

Healthcare Inspections (54F) 

1. I concur with the findings and recommendations of the Office of 

Inspector General Community Based Outpatient Clinic Review of the 

Cambridge and Fort Howard, MD and Alexandria, VA and Greenbelt, 

MD clinics, as well as the action plan developed by the Washington, DC 

VAMC. 

2. We appreciate the opportunity for this review as a continuing process 

to improve the care to our veterans. 

3. If further information is required, please contact Ruthanne Burris, 

MBA, RN, Director of Quality Management, DC VA Medical Center, at 

(202) 745-8564. 
CBOC Reviews: Cambridge and Fort Howard, Alexandria and Greenbelt, Wilmington and Jacksonville 

Appendix B 

VA Maryland HCS Director Comments 

VA Office of Inspector General 22 

Department of 

Veterans Affairs Memorandum

Date: September 11, 2009 

From: Director, VA Maryland HCS (512/00) 

Subject: Healthcare Inspection – CBOC Reviews: Cambridge and 

Fort Howard, MD

To: Director, VISN 5 (10N5) 

1. The VAMHCS concurs with the results of the review of two 

of our CBOCs. We are pleased with the results and will use 

them as motivation across the VAMHCS. 

2. The professionalism and cooperative manner demonstrated by 

the team was appreciated by all involved. 

3. The experience, in an area that had not previously been 

reviewed individually, not only reinforced positive work 

practices but encouraged staff to continue to improve the 

quality of care to our veterans. 

4. If you have any additional questions, please contact Iris E. 

Pettigrew, Director Performance Improvement and 

Accreditation. 
CBOC Reviews: Cambridge and Fort Howard, Alexandria and Greenbelt, Wilmington and Jacksonville

Appendix C 

Washington DC VAMC Director Comments

VA Office of Inspector General 23 

Department of 

Veterans Affairs Memorandum

Date: September 11, 2009 

From: Fernando O. Rivera, FACHE 

Director, Washington DC VAMC (688/00) 

Subject: Healthcare Inspection – CBOC Reviews: Alexandria, VA and 

Greenbelt, MD

To: Sanford Garfunkel 

Director, VISN 5 (10N5) 

 
CBOC Reviews: Cambridge and Fort Howard, Alexandria and Greenbelt, Wilmington and Jacksonville

VA Office of Inspector General 24 

Washington DC 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 5 Director ensure 

that the Washington DC VAMC Director requires physician privileges are 

appropriate to the procedures performed at each CBOC. 

Concur Target Completion Date: October 1, 2009

Privileging procedures have been revised and sent for approval to the Chief 

of Medicine service. 

Recommendation 2. We recommended that the VISN 5 Director ensure 

that the Washington DC VAMC Director requires both CBOCs to utilize PI 

data during the reprivileging process. 

Concur Target Completion Date: October 1, 2009

Performance improvement data has been incorporated into the quarterly 

provider reviews, with the inclusion of three new indicators. 

Recommendation 3. We recommended that the VISN 5 Director ensure 

that the Washington DC VAMC Director requires auditory privacy be 

maintained during the check-in at both Alexandria and Greenbelt CBOCs. 

Concur Target Completion Date: October 1, 2009

Evaluation of both CBOCs has been completed. While structural 

constraints exist that prevent physical relocation of the reception desks at 

either CBOC, alternative measures have been implemented through posted 

signage regarding respect for privacy, physical separation of queue from 

patient in process, and insertion of patient information sheets within folders 

outside provider offices. 
CBOC Reviews: Cambridge and Fort Howard, Alexandria and Greenbelt, Wilmington and Jacksonville

VA Office of Inspector General 25 

Recommendation 4. We recommended that the VISN 5 Director ensure 

that the Washington DC VAMC Director requires appropriate protective 

screens be applied to the monitors at the Greenbelt CBOC. 

Concur Target Completion Date: September 1, 2009 

Privacy screens have been added to monitors at Greenbelt.

Recommendation 5. We recommended that the VISN 5 Director ensure 

that the Washington DC VAMC Director determines the appropriateness of 

an internal panic alarm system at both Alexandria and Greenbelt CBOCs. 

Concur Target Completion Date: November 30, 2009

An evaluation for internal panic alarm options is currently being conducted 

by Police/Security, with quotes requested from the alarm vendor. A final 

determination will be completed once all assessment information has been 

received. 

Recommendation 6. We recommended that the VISN 5 Director ensure 

that the Washington DC VAMC Director requires that the locations of all 

fire extinguishers are properly identified at the Greenbelt CBOC. 

Concur Target Completion Date: October 1, 2009

An assessment has been completed and signage has been ordered. 

Recommendation 7. We recommended that the VISN 5 Director ensure 

that the Washington DC VAMC Director requires both Alexandria and 

Greenbelt CBOCs revise the local SOP for medical emergencies to reflect 

the current practices and revise the mental health SOP to include 

intervention for disruptive and violent behavior. 

Concur Target Completion Date: October 1, 2009

SOPs have been revised to include medical and psychiatric emergencies 

that address use of medications, as well as appropriate interventions for 

disruptive/violent behaviors, to reflect current practices within the CBOCs. 

Final draft has been approved. SOP distribution and education is underway. 
CBOC Reviews: Cambridge and Fort Howard, Alexandria and Greenbelt, Wilmington and Jacksonville 

Appendix D 

VISN 6 Director Comments 

VA Office of Inspector General 26 

Department of 

Veterans Affairs Memorandum

Date: September 16, 2009 

From: Director, VISN 6 (10N6) 

Subject: Healthcare Inspection – CBOC Review: Wilmington and 

Jacksonville, NC 

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

Healthcare Inspections (54F) 

I concur with the findings, and with the specific corrective actions planned 

for each recommendation by the Fayetteville VAMC Director. 

 (original signed by:)

DANIEL F. HOFFMANN, FACHE 

 
CBOC Reviews: Cambridge and Fort Howard, Alexandria and Greenbelt, Wilmington and Jacksonville

Appendix E 

Fayetteville VAMC Comments 

VA Office of Inspector General 27 

Department of 

Veterans Affairs Memorandum

Date: September 15, 2009 

From: Director, Fayetteville VAMC (565/00) 

Subject: Healthcare Inspection – CBOC Review: Wilmington and 

Jacksonville, NC 

To: Director, VISN 6 (10N6) 

Fayetteville VA Medical Center concurs with findings. We have provided the 

specific corrective actions planned for each recommendation. 

(original signed by:)

Bruce C. Triplett 
CBOC Reviews: Cambridge and Fort Howard, Alexandria and Greenbelt, Wilmington and Jacksonville

Fayetteville 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 8. We recommended that the VISN 6 Director ensure 

that the Fayetteville VAMC Director requires that PSB grant privileges 

consistent with the services provided at both Wilmington and Jacksonville 

CBOCs. 

Concur Target Completion Date: 10/30/09

The Chief, Primary Care Service has reviewed all privileges to ensure these 

are consistent with the services provided at both Wilmington and 

Jacksonville CBOCs. Adjustment to current privileges is planned to be 

completed at the next scheduled Professional Standards Board currently 

planned in the month of September, 2009. 

Recommendation 9. We recommended that the VISN 6 Director ensure 

that the Fayetteville VAMC Director requires consistent monitoring of 

collaborative practice at the Wilmington CBOC. 

Concur Target Completion Date: 10/30/09

The Chief, Primary Care has identified the collaborative practice physician 

for oversight of the Physician’s Assistant scope of practice at the 

Wilmington CBOC. Monthly monitoring is consistently ensured by 

reviewing the required minimum of ten medical records per month as part 

of our ongoing provider evaluation. Results will be reported to the Chief of 

Primary Care Service Line. 

Recommendation 10. We recommended that the VISN 6 Director ensure 

that the Fayetteville VAMC Director requires that processes be 

implemented to secure and protect personally identifiable information at the 

Wilmington CBOC. 

Concur Target Completion Date: 10/30/09

VA Office of Inspector General 28 
CBOC Reviews: Cambridge and Fort Howard, Alexandria and Greenbelt, Wilmington and Jacksonville

Training is currently scheduled with the Information Security Officer (ISO) 

and the Privacy Officer (PO) of the Fayetteville VAMC, September 16, 

2009 and on October 7, 2009. Written information has already been 

provided to all the staff. Compliance with the effectiveness of the training 

will be measured via random rounds by the Clinic Nurse Manager and the 

results will be reported to the Nurse Executive Council and the Medical 

Executive Board. 

Recommendation 11. We recommended that the VISN 6 Director ensure 

that the Fayetteville VAMC Director examines the existing medication 

management processes to ensure quality and safety standards are met when 

dispensing the outpatient medications at both Wilmington and Jacksonville 

CBOCs. 

Concur Target Completion Date: 9/14/09

Written instructions on the physician order entry in the computerized 

medical records has been communicated to all CBOC providers. 

Additionally, a test order entry was completed by each provider to ensure 

competency in the computerized physician order entry and to ensure that 

quality and safety standards are met. A random sample of 10 orders per 

month per CBOC will be reviewed and the results will be reported to the 

Primary Care Service Line. 

Recommendation 12. We recommended that the VISN 6 Director ensure 

that the Fayetteville VAMC Director requires a panic alarm system is 

installed at the Wilmington CBOC. 

Concur Target Completion Date: 10/30/09

Installation of the Panic Alarm system commenced on August 31, 2009. 

Completion is expected during the last week of September. 

Recommendation 13. We recommended that the VISN 6 Director ensure 

that the Fayetteville VAMC Director requires that patients in wheelchairs 

or with other assistive devices have proper access to the Jacksonville 

CBOC. 

Concur Target Completion Date: 10/30/09

Wiring for the handicap assist buttons was started the week of September 9, 

2009. Assist buttons on doors are expected to be operational by the last 

week of September. 

VA Office of Inspector General 29 
CBOC Reviews: Cambridge and Fort Howard, Alexandria and Greenbelt, Wilmington and Jacksonville

VA Office of Inspector General 30 

Recommendation 14. We recommended that the VISN 6 Director ensure 

that Fayetteville VAMC Director provides contract oversight and 

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

contract for the Wilmington CBOC. 

Concur Target Completion Date: 9/11/09

Contract with Magnum Joint Venture/Sterling Medical was not renewed 

and ended on May 30, 2009. 

Recommendation 15. We recommended that the VISN 6 Director ensure 

that the Fayetteville VAMC Director takes steps to recover overcharges on 

billings for Wilmington CBOC enrollees who have not received services in 

the prior 12 months. 

Concur Target Completion Date: 10/30/09

Plans are underway to initiate a bill of collection to the former contractor, 

Magnum Joint Venture/Sterling Medical. 
CBOC Reviews: Cambridge and Fort Howard, Alexandria and Greenbelt, Wilmington and Jacksonville 

Appendix F 

CBOC Characteristics 

CBOC Station Number CBOC Name Parent VA Specialty Care Cardiology Gastrointestinal Occupational Therapy Optometry Rheumatology Physical Therapy Podiatry Urology 

512GA Cambridge, MD Maryland HCS Yes No No Yes Yes No No No Yes 

512GF Fort Howard, MD Maryland HCS Yes No No No No Yes No Yes No 

688GA Alexandria, VA Washington DC VAMC No No No No No No No No Yes 

688GC Greenbelt, MD Washington DC VAMC No No No No No No No No Yes 

565GC Wilmington, NC Fayetteville VAMC No No No No No No No No No 

565GA Jacksonville, NC Fayetteville VAMC No No No No No No No No No 

Specialty Care Services 

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

512GA Cambridge, MD Maryland HCS Yes No No Yes Yes No Yes 

512GF Fort Howard, MD Maryland HCS Yes No No Yes Yes Yes No 

688GA Alexandria, VA Washington DC VAMC Yes No No Yes No Yes Yes 

688GC Greenbelt, MD Washington DC VAMC Yes No No Yes No Yes Yes 

565GC Wilmington, NC Fayetteville VAMC Yes No No Yes Yes Yes No 

565GA Jacksonville, NC Fayetteville VAMC Yes No No Yes Yes No No 

Onsite Services 

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

512GA Cambridge, MD Maryland HCS Yes Yes Yes Yes Yes Yes Yes 

512GF Fort Howard, MD Maryland HCS Yes Yes Yes No Yes Yes Yes 

688GA Alexandria, VA Washington DC VAMC Yes No No Yes Yes No No 

688GC Greenbelt, MD Washington DC VAMC Yes No Yes Yes No No No 

565GC Wilmington, NC Fayetteville VAMC Yes No Yes Yes No Yes No 

565GA Jacksonville, NC Fayetteville VAMC Yes No Yes Yes No Yes No 

Mental Health Services 

VA Office of Inspector General 31 
CBOC Reviews: Cambridge and Fort Howard, Alexandria and Greenbelt, Wilmington and Jacksonville

VA Office of Inspector General 32 CBOC Station Number CBOC Name Internal Medicine Physician Primary Care Physician Nurse Practitioner Physician Assistant Registered Nurse LPN Psychologist Pharmacist Social Worker Dietary Technician/ Technologists Administrative/ Clerical Other 

512GA Cambridge, MD Yes Yes Yes No Yes No Yes Yes Yes Yes Yes Yes No

512GF Fort Howard, 

MD 

Yes Yes Yes Yes Yes No Yes Yes Yes No No Yes No

688GA Alexandria, VA No Yes Yes No Yes No No No No Yes No Yes No

688GC Greenbelt, MD No Yes Yes No Yes No Yes No No Yes No Yes No

565GC Wilmington, NC No Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 

565GA Jacksonville, NC No Yes No No Yes Yes Yes Yes Yes No Yes Yes 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 

512GA Cambridge, MD Maryland HCS Rural 124 Yes No Yes Yes 

512GF Fort Howard, MD Maryland HCS Urban 18.4 No No Yes No 

688GA Alexandria, VA Washington DC VAMC Urban 17.46 Yes Yes No Yes 

688GC Greenbelt, MD Washington DC VAMC Urban 11.56 Yes Yes No Yes 

565GC Wilmington, NC Fayetteville VAMC Urban 94.26 Yes Yes No No 

565GA Jacksonville, NC Fayetteville VAMC Urban 104.87 Yes Yes No No 

Type of Location, Availability of Public 

 Transportation, and Participation in Tele-medicine 
CBOC Reviews: Cambridge and Fort Howard, Alexandria and Greenbelt, Wilmington and Jacksonville 

Appendix G 

Quality of Care Measures 

VA Maryland HCS – Cambridge and Fort Howard 

Measure Facility 

Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 Percentage 

Hyperlipidemia 

Screen 

National 13,148 13,587 97 

512 Maryland HCS 92 98 94 

 512GA Cambridge 40 41 98 

 512GF Fort Howard 41 44 93 

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 

512 Maryland HCS 37 44 84 

512GA Cambridge 38 38 100 

512GF Fort Howard 30 33 91 

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 

512 Maryland HCS 37 44 84 

512GA Cambridge 38 38 100 

512GF Fort Howard 30 33 91 

Foot Pedal Pulses, FY 2009 

Measure Facility Qtr 1 Qtr 1 Qtr 1 

 Numerator Denominator Percentage 

DM - Outpatient - Foot 

Sensory Exam Using 

Monofilament 

National 5,266 5,951 88 

512 Maryland HCS 41 45 91 

512GA Cambridge 36 38 95 

512GF Fort Howard 28 33 85 

Foot Sensory, FY 2009 

Measure Meets 

Target 

Facility Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 

Percentage 

DM – Retinal 

Eye Exam 

88 National 4,599 5,258 87 

88 512 Maryland HCS 28 34 82 

512GA Cambridge 36 38 95 

512GF Fort Howard 27 33 82 

Retinal Exam, FY 2009 

VA Office of Inspector General 33 
CBOC Reviews: Cambridge and Fort Howard, Alexandria and Greenbelt, Wilmington and Jacksonville

VA Office of Inspector General 34 

Measure Meets 

Target 

Facility Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 Percentage 

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

95 512 Maryland HCS 32 34 94 

512GA Cambridge 37 38 97 

512GF Fort Howard 31 33 94 

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 

93 512 Maryland HCS 30 34 88 

512GA Cambridge 35 38 92 

512GF Fort Howard 28 33 84 

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 

90 512 Maryland HCS 57 59 97 

512GA Cambridge 16 16 100 

512GF Fort Howard 4 4 100 

PTSD Screening, FY 2009 
CBOC Reviews: Cambridge and Fort Howard, Alexandria and Greenbelt, Wilmington and Jacksonville 

Appendix H 

Quality of Care Measures 

Washington DC VAMC – Alexandria and Greenbelt 

Measure Facility 

Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 Percentage 

Hyperlipidemia 

Screen 

National 13,148 13,587 97 

688 Washington DC VAMC 100 100 100 

 688GA Alexandria 10 10 100 

 688GC Greenbelt 11 11 100 

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 

688 Washington DC VAMC 49 51 96 

688GA Alexandria 40 43 93 

688GC Greenbelt 45 48 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 

688 Washington DC VAMC 49 51 96 

688GA Alexandria 40 43 93 

688GC Greenbelt 46 48 96 

Foot Pedal Pulses, FY 2009 

Measure Facility Qtr 1 Qtr 1 Qtr 1 

 Numerator Denominator Percentage 

DM - Outpatient - Foot 

sensory exam using 

monofilament 

National 5,266 5,951 88 

688 Washington DC VAMC 49 51 96 

688GA Alexandria 40 43 93 

688GC Greenbelt 46 48 96 

Foot Sensory, FY 2009 

Measure Meets 

Target 

Facility Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 

Percentage 

DM – Retinal 

Eye Exam 

88 National 4,599 5,258 87 

88 688 Washington DC VAMC 42 46 91 

688GA Alexandria 42 43 98 

688GC Greenbelt 40 48 83 

Retinal Exam, FY 2009 

VA Office of Inspector General 35 
CBOC Reviews: Cambridge and Fort Howard, Alexandria and Greenbelt, Wilmington and Jacksonville

VA Office of Inspector General 36 

Measure Meets 

Target

 

Facility Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 

Percentage 

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

95 688 Washington DC VAMC 41 44 93 

688GA Alexandria 43 43 100 

688GC Greenbelt 47 48 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 

93 688 Washington DC VAMC 41 46 89 

688GA Alexandria 42 43 98 

688GC Greenbelt 47 48 98 

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 

90 688 Washington DC VAMC 62 63 98 

688GA Alexandria 23 23 100 

688GC Greenbelt 17 17 100 

PTSD Screening, FY 2009 

Measure Meets 

Target 

Facility Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 

Percentage 

Patient Screen with 

PC-PTSD with

Timely Suicide 

Ideation/Behavior 

Evaluation 

60 National 32 55 62 

60 688 Washington DC VAMC * * * 

688GC Greenbelt 1 1 100 

PTSD Screening with Timely Suicide Ideation/Behavior Evaluation, FY 2009 

 Null values are represented by *, indicating no eligible cases. 
CBOC Reviews: Cambridge and Fort Howard, Alexandria and Greenbelt, Wilmington and Jacksonville 

Appendix I 

Quality of Care Measures 

Fayetteville VAMC – Wilmington and Jacksonville 

Measure Facility 

Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 Percentage 

Hyperlipidemia 

Screen 

National 13,148 13,587 97 

565 Fayetteville VAMC 91 96 95 

 565GC Wilmington 50 50 100 

 565GA Jacksonville 29 29 100 

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 

565 Fayetteville VAMC 37 38 97 

565GC Wilmington 43 47 91 

565GA Jacksonville 10 11 91 

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 

565 Fayetteville VAMC 37 38 97 

565GC Wilmington 43 47 91 

565GA Jacksonville 9 11 82 

Foot Pedal Pulses, FY 2009 

Measure Facility Qtr 1 Qtr 1 Qtr 1 

 Numerator Denominator Percentage 

DM - Outpatient - 

Foot Sensory Exam 

Using Monofilament 

National 5,266 5,951 88 

565 Fayetteville VAMC 37 38 97 

565GC Wilmington 43 47 91 

565GA Jacksonville 9 11 82 

Foot Sensory, FY 2009 

Measure Meets 

Target 

Facility Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 

Percentage 

DM – 

Retinal 

Eye Exam 

88 National 4,599 5,258 87 

88 565 Fayetteville VAMC 30 33 91 

565GC Wilmington 39 47 83 

565GA Jacksonville 11 12 92 

Retinal Exam, FY 2009 

VA Office of Inspector General 37 
CBOC Reviews: Cambridge and Fort Howard, Alexandria and Greenbelt, Wilmington and Jacksonville

VA Office of Inspector General 38 

Measure Meets 

Target 

Facility Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 

Percentage 

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

95 565 Fayetteville VAMC 32 33 97 

565GC Wilmington 39 47 83 

565GA Jacksonville 12 12 100 

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 

93 565 Fayetteville VAMC 32 33 97 

565GC Wilmington 43 47 91 

565GA Jacksonville 8 12 67 

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 

90 565 Fayetteville VAMC 32 33 97 

565GC Wilmington 21 21 100 

565GA Jacksonville 17 17 100 

PTSD Screening, FY 2009 

Measure Meets 

Target 

Facility Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 

Percentage 

Patient Screen with PCPTSD with timely Suicide 

Ideation/Behavior 

Evaluation 

60 National 32 55 62 

90 565 Fayetteville 1 1 100 

565GC Wilmington * * 

565GA Jacksonville * * 

PTSD Screening with Timely Suicide Ideation/Behavior Evaluation, FY 2009 

 Null values are represented by *, indicating no eligible cases.
CBOC Reviews: Cambridge and Fort Howard, Alexandria and Greenbelt, Wilmington and Jacksonville 

Appendix J 

OIG Contact and Staff Acknowledgments 

OIG Contact Marisa Casado, Director 

CBOC Program Review 

(727) 395-2416 

Acknowledgments Wachita Haywood, Associate Director 

Nancy Albaladejo, RN, MSA 

Jennifer Christensen, DPM 

Lin Clegg, Ph.D. 

Marnette Dhooghe, MS 

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 

VA Office of Inspector General 39 
CBOC Reviews: Cambridge and Fort Howard, Alexandria and Greenbelt, Wilmington and Jacksonville

Appendix K 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VISN 5 (10N5) 

Director, VISN 6 (10N6) 

Director, VA Maryland HCS (512/00) 

Director, Washington DC VAMC (688/00) 

Director, Fayetteville VAMC (565/00) 

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: Richard Burr, Benjamin L. Cardin, Kay R. Hagan, Barbara A. Mikulski, 

Mark R. Warner, Jim Webb 

U.S. House of Representatives: Steny Hoyer, Frank Kratovil, Walter Jones, Mike 

McIntyre, Jim Moran, Dutch Ruppersberger 

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

VA Office of Inspector General 40