Department of Veterans Affairs 

Office of Inspector General 

Healthcare Inspection 

Community Based Outpatient 

Clinic Reviews 

Lockport and Olean, NY 

Monaca and Washington, PA 

Berwick and Sayre, PA 

Somerset, KY 

Report No. 09-01446-226 September 23, 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: Lockport and Olean, Monaca and Washington, Berwick and Sayre, and Somerset 

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............................................................................4 

IV. Results and Recommendations.....................................................................5 

A. VISN 2, VA Western New York HCS – Lockport and Olean................................. 5 

B. VISN 4, VA Pittsburgh HCS – Monaca and Washington ....................................... 9 

C. VISN 4, Wilkes-Barre VAMC – Berwick and Sayre ............................................ 15 

D. VISN 9, Lexington VAMC – Somerset................................................................. 23 

Appendixes

A. VISN 2 Director Comments................................................................................... 25 

B. VA Western New York HCS Director Comments ................................................ 26 

C. VISN 4 Director Comments................................................................................... 28 

D. VA Pittsburgh HCS Director Comments............................................................... 29 

E. Wilkes-Barre VAMC Director Comments............................................................. 32 

F. VISN 9 Director Comments ................................................................................... 36 

G. Lexington VAMC Director Comments.................................................................. 37 

H. CBOC Characteristics ............................................................................................ 39 

I. Quality of Care Measures – Lockport and Olean.................................................... 41 

J. Quality of Care Measures – Monaca and Washington............................................ 43 

K. Quality of Care Measures – Berwick and Sayre.................................................... 45 

L. Quality of Care Measures – Somerset.................................................................... 47 

M. OIG Contact and Staff Acknowledgments............................................................ 49

N. Report Distribution................................................................................................. 50 

VA Office of Inspector General 
CBOC Reviews: Lockport and Olean, Monaca and Washington, Berwick and Sayre, and Somerset 

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 seven CBOCs 

during the week of July 13–17, 2009. The CBOCs reviewed in VISN 2 were Lockport 

and Olean, NY; in VISN 4, Monaca and Washington, PA; and Berwick and Sayre, PA; 

and, in VISN 9, Somerset KY. The parent facilities of these CBOCs are VA Western NY 

Healthcare System (HCS), VA Pittsburgh HCS, Wilkes-Barre VA Medical Center 

(VAMC), and Lexington 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 2, 4 and 9, in conjunction with the respective facility manager, should take 

appropriate actions on the following recommendations: 

• Require that contract providers are privileged according to VHA policy. 

• Accomplish providers’ background checks according to VHA policy. 

• Require physician assistants are consistently monitored and evaluated by the 

collaborative physician and that results of the evaluations are used during the recredentialing process. 

• Ensure clinical competencies are monitored by the appropriate discipline. 

• Ensure staff are trained, evaluated, and that the competencies are documented. 

• Conduct a security risk assessment and evaluate the assessment to determine 

appropriate measures. 

• Implement appropriate measures as described in the vulnerability review. 

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

• Take appropriate actions to secure and protect health records. 

• Provide proper CBOC access to disabled patients. 

VA Office of Inspector General i 
CBOC Reviews: Lockport and Olean, Monaca and Washington, Berwick and Sayre, and Somerset 

VA Office of Inspector General ii 

• Adhere to manufacturer’s equipment maintenance requirements. 

• Ensure pharmaceuticals are dispensed according to VHA policy. 

• Properly reprocess reusable medical equipment. 

• Develop and maintain an emergency management plan that includes emergency 

response to all mental health emergencies and reflects current practices. 

• Recover overcharges from the contractor and ensure that future invoices are 

verified for compliance with contract provisions. 

• Ensure information is accurate and complete on contractor billings. 

• Formalize the contractual agreement with the contractor regarding the “Point of 

Care” addendum. 

Comments 

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

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

pages 25–38, for the full text of the Directors’ comments.) We will follow up on the 

planned actions until they are completed. 

 (original signed by:)

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

Assistant Inspector General for 

Healthcare Inspections 
CBOC Reviews: Lockport and Olean, Monaca and Washington, Berwick and Sayre, and Somerset 

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 VA medical center (VAMC) outpatient clinics. 

• Determine whether CBOC providers are appropriately credentialed and privileged 

in accordance to VHA Handbook 1100.19.1

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

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

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

 

1

 VHA Handbook 1100.19, Credentialing and Privileging, November 14, 2008. 
CBOC Reviews: Lockport and Olean, Monaca and Washington, Berwick and Sayre, and Somerset 

VA Office of Inspector General 2 

• Determine whether CBOCs are in compliance with standards of operations 

according to VHA Handbook 1006.12

 in the areas of environmental safety and 

emergency planning. 

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

• Determine whether CBOC contracts are administered in accordance with contract 

terms and conditions. 

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

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

samples of 50 patients with a diagnosis of diabetes, 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: Lockport and Olean, Monaca and Washington, Berwick and Sayre, and Somerset 

Part II. CBOC Characteristics 

Veterans Integrated Service Network (VISN) 2 has 6 VHA hospitals and 30 CBOCs, 

VISN 4 has 10 VHA hospitals and 45 CBOCs, and VISN 9 has 7 hospitals and 

50 CBOCs. As part of our review, we inspected 7 CBOCs (3 VA staffed and 4 with 

contracted staff). The CBOCs reviewed in VISN 2 were Lockport and Olean, NY; in 

VISN 4, Monaca and Washington, PA; and Berwick and Sayre, PA; and, in VISN 9, 

Somerset KY. The parent facilities of these CBOCs are VA Western NY Healthcare 

System (HCS), VA Pittsburgh HCS, Wilkes-Barre VAMC, and Lexington 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 3 VA-staffed CBOCs was 

3,377 (range 2,104 to 4,363) and at the contract CBOCs was 3,108 (range 1,060 to 

4,850). Figure 1 shows characteristics of the 7 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 

2 Lockport, NY Western NY HCS Contract Urban 1.0 1,060 2,689 

2 Olean, NY Western NY HCS VA Staffed Urban 2.0 2,104 4,790 

4 Monaca, PA Pittsburgh HCS Contract Urban 3.0 4,367 16,062 

4 Washington, PA Pittsburgh HCS Contract Urban 4.6 4,850 17,948 

4 Berwick, PA Wilkes-Barre VAMC Contract Rural 2.02 2,155 6,134 

4 Sayre, PA Wilkes-Barre VAMC VA Staffed Rural 4.0 3,663 31,099 

9 Somerset, KY Lexington VAMC VA Staffed Rural 3.65 4,363 17,556 

Figure 1 - CBOC Characteristics, FY 2008 

All seven CBOCs have laboratory services and perform electrocardiograms (EKGs) 

onsite. Two CBOCs have an onsite Pharmacy, and three CBOCs provided radiological 

services. Social Work services are also available at six CBOCs. 

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

the CBOCs to include, psychiatrists, social workers, and nurse practitioners. Tele-mental 

health is also available at five CBOCs. Five of the CBOCs provided MH services 5 days 

a week (Olean, Monaca, Washington, Sayre, and Somerset), 1 (Lockport) 2 days per 

week and every other Thursday, and 1 (Berwick) 4 days per week. Additional CBOC 

characteristics are listed in Appendix H.

VA Office of Inspector General 3 
CBOC Reviews: Lockport and Olean, Monaca and Washington, Berwick and Sayre, and Somerset 

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 four CBOC contracts (Lockport, Monaca, Washington, and 

Berwick) 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 4 
CBOC Reviews: Lockport and Olean, Monaca and Washington, Berwick and Sayre, and Somerset 

Part IV. Results and Recommendations 

A. VISN 2, VA Western New York HCS – Lockport and Olean 

Quality of Care Measures 

The Olean CBOC scores exceeded the parent facility for hyperlipidemia screening while 

the Lockport CBOC’s scores were lower. Both CBOCs scored higher than the parent 

facility for the following measures: diabetes mellitus (DM) foot inspections, pedal 

pulses, foot sensory exams using monofilament, retinal eye examinations, and PTSD 

screening. Lockport CBOC’s renal testing score was lower than the parent facility while 

the Olean CBOC scored higher, scoring 100 percent. (See Appendix I.) 

Credentialing and Privileging 

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

the Olean CBOC and two providers and three nurses at the Lockport CBOC. All 

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

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

following area that needed improvement: 

Privileging of Contract Providers 

VHA Handbook 1100.19 states that clinical privileges granted to contractors may not 

extend beyond the contract period. The contract providers at the Lockport CBOC were 

privileged for a 2-year period while the contract was granted for only 1 year. 

Recommendation 1. We recommended that the VISN 2 Director ensure that the VA 

Western New York HCS Director requires that contract providers at the Lockport CBOC 

are privileged according to policy. 

The VISN and HCS Directors concurred with our finding and recommendation. Contract 

providers’ C&P will reflect the contract period. The improvement plans are acceptable, 

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

Environment and Emergency Management 

Environment of Care

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

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

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

VA Office of Inspector General 5 
CBOC Reviews: Lockport and Olean, Monaca and Washington, Berwick and Sayre, and Somerset 

Panic Alarms 

The Olean CBOC provides MH services but did not have panic alarms for either the 

administrative or the clinical staff. The staff indicated that if they felt threatened and 

needed assistance, they would call out for help and try to leave the room. The parent 

facility conducted a vulnerability review in May 2009 and recommended the installation 

of a panic alarm system; however, no action for the installation of an alarm system had 

been implemented at the time of our inspection. 

Recommendation 2. We recommended that the VISN 2 Director ensure that the VA 

Western New York HCS Director implements the recommendation to install a panic 

alarm system at the Olean CBOC. 

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

mechanism will be installed to alert staff members at the Olean CBOC that a crisis 

situation is occurring. 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 standard operating 

procedure (SOP) defining how medical emergencies, including MH emergencies, are 

handled. The Olean CBOC had a local policy during FY 2008 that addressed MH 

emergencies; however, the plan did not address medical emergencies. The policy was 

revised in June 2009 to include medical emergencies. Our interviews revealed that staff 

responses were in compliance to the revised policy. Because the CBOC revised the 

policy prior to this review, we made no recommendation. 

Automated External Defibrillator 

The Lockport CBOC’s contract states that an Automated External Defibrillator (AED) 

will be provided and maintained by the HCS. We found that the AED stationed at the 

CBOC was provided by the contractor and not the HCS. Staff received training on VA 

purchased equipment; however, the equipment was not provided to the CBOC. We were 

told that a VA-purchased AED was on order for this CBOC; and, during the time of our 

visit, the equipment was delivered. Because the HCS delivered the AED during this 

review, we made no recommendation. 

VA Office of Inspector General 6 
CBOC Reviews: Lockport and Olean, Monaca and Washington, Berwick and Sayre, and Somerset 

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) 

528 Buffalo Mean 

Score 

82.1 84.2 82.4 84.1 78.5 

N= 86 79 77 2,288 54,400 

528GK Lockport 81.6 91.5 91.8 

 N= 84 83 91 

528GR Olean 79.6 89.6 88.3 

N= 85 72 80 

Figure 2. Outpatient Overall Quality 

Both CBOCs’ “overall quality” indicator scored higher than the parent facility, VISN, 

and national for the 2nd and 3rd Qtrs. However, both CBOCs were slightly lower than the 

parent facility during the 4th 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) 

528 Buffalo Mean 

Score 

83.2 92.8 90.4 88.6 77.3 

 N= 87 80 79 2,353 55,407 

528GK Lockport 93.9 98.7 98.3 

 N= 81 84 89 

528GR Olean 91.8 99.8 96.4 

N= 92 74 79 

Figure 3. Provider Wait Times 

Both CBOCs” “provider wait time” indicator scored higher than the parent facility, 

VISN, and national during the 2nd, 3rd, and 4th Qtrs. 

VA Office of Inspector General 7 
CBOC Reviews: Lockport and Olean, Monaca and Washington, Berwick and Sayre, and Somerset 

CBOC Contract 

Lockport CBOC 

The contract for the Lockport CBOC is administered through the VA Western New York 

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

continuity of care for all eligible veterans in VISN 2. Contracted services with CR 

Associates, Inc. began on July 1, 2008, with option years extending through June 30, 

2013. Their current contract was administered under the base year for the period July 1, 

2008, through June 30, 2009. The contract terms state that the CBOC will have (1) a 

New York licensed physician to serve as medical director and (2) other primary care 

providers to include physicians’ assistants (PAs) and nurse practitioners. There was one 

FTE primary care provider for the 1st Qtr, FY 2009. The contractor was compensated by 

the number of enrollees at a monthly capitated rate per enrollee. The CBOC had 1,060 

unique primary medical care enrollees with 2,689 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 

HCS 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 and found them consistent with supporting documentation and the terms of 

the contract. We reviewed capitation rates for compliance with the contract; form and 

substance of the contract invoices for ease of data analysis by the Contracting Officer’s 

Technical Representative (COTR); and duplicate, missing, or incomplete social security 

numbers (SSNs) on the invoices. 

Based upon our inspection of the contract, invoices, and other supporting documents for 

Lockport, there were no findings or recommendations noted for the period October 1 

through December 31, 2008. 

VA Office of Inspector General 8 
CBOC Reviews: Lockport and Olean, Monaca and Washington, Berwick and Sayre, and Somerset 

VA Office of Inspector General 9 

B. VISN 4, VA Pittsburgh HCS – Monaca and Washington 

Quality of Care Measures 

Both the Monaca and the Washington CBOCs equaled or exceeded the parent facility 

with the following exceptions. Washington scored less than the parent facility in the 

following measures: DM retinal assessment, DM lipid profile, and PTSD screening. (See 

Appendix J.) 

Credentialing and Privileging 

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

Monaca CBOC and five providers and three nurses at the Washington CBOC. All 

providers possess a full, active, current, and unrestricted license. Additionally, the parent 

facility had a system in place to monitor the quality of care provided by licensed 

independent practitioners to veterans. The parent facility had a plan in place to remediate 

and improve performance when reviews did not reveal provider adherence to expected 

performance. The nurses’ personnel folders were well organized and contained the 

required documentation. However, we identified the following area that needed 

improvement: 

Background Checks 

According to VHA Directive 0710,3

 all Federal appointments are subject to background 

checks. The Office of Personnel Management (OPM) conducts the background checks. 

The HCS was unable to provide evidence that OPM had conducted a background check 

for one of five providers reviewed at the Washington CBOC. At the time of this review, 

the HCS did not keep copies of contracted provider background checks on file and did 

not have a system in place to assure these background checks had been completed. 

Recommendation 3. We recommended that the VISN 4 Director ensure that the 

Pittsburgh VA HCS Director requires that Washington CBOC background checks are 

completed in accordance with VHA requirements. 

The VISN and HCS Directors concurred with our finding and recommendation. A new 

system has been created to ensure background checks are completed in accordance with 

VHA requirements. The improvement plans are acceptable, and we will follow up on the 

planned actions until they are completed. 

 

3

 VHA Directive 0710, Personnel Security and Suitability Program, May 18, 2007. 
CBOC Reviews: Lockport and Olean, Monaca and Washington, Berwick and Sayre, and Somerset 

VA Office of Inspector General 10 

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 were generally clean and safe. 

However, we found the following area that needed improvement: 

Auditory Privacy 

Auditory privacy was inadequate for patients during the check-in process at the 

Washington CBOC. The VA requires auditory privacy when staff discuss sensitive 

patient issues.4

 At the Washington CBOC, patients communicate with staff through a 

slide-open glass window located in the waiting area. Waiting room seats are located next 

to the check-in window. During our observations, patients were asked their names, the 

last four numbers of their SSN, and the reason for their visit. Patient conversations were 

easily heard by others in the waiting room area. 

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

Pittsburgh HCS Director requires auditory privacy be maintained during the check-in 

process at the Washington CBOC. 

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

waiting area at the Washington CBOC has been reconfigured to maintain auditory 

privacy during the check-in process. The improvement plans are acceptable, and we will 

follow up on the planned actions until they are completed. 

Emergency Management 

During interviews, the Monaca CBOC staff indicated they would call the local 

emergency response system (911) if an actively suicidal or homicidal person presented to 

the CBOC. However, the CBOC did not have a local policy in effect that directed staff to 

call 911 in these circumstances. We did learn the CBOC was in the process of 

developing a MH emergency management plan that included calling 911 in MH 

emergency situations where there is an immediate threat to life. 

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

Pittsburgh HCS Director requires that Monaca CBOC have an emergency management 

plan that includes emergency response to all MH emergencies. 

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

emergency plan for the Monaca CBOC has been revised to include procedures for MH 

 

4 VHA Handbook 1605.1, Privacy and Release of Information, May 17, 2006.
CBOC Reviews: Lockport and Olean, Monaca and Washington, Berwick and Sayre, and Somerset 

emergencies, and orientation has been provided to all staff. The improvement plans are 

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

Patient Satisfaction 

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

Trip Pak Report - STA5 Level 

Patient Perceptions of Care 

2008 SHEP Performance Measures 

YTD Through September 2008 

Performance 

Measure (SHEP 

question #) 

Station 

Number 

Facility Name Data 

Type 

FY08 

Qtr 4 

FY08 

Qtr 3 

FY08 

Qtr 2 

VISN 

FY08, 

Qtr 4 

National 

FY08, 

Qtr 4 

(Q56) - Outpatients 

(percent Very 

Good, Excellent) 

646 Pittsburgh Mean 

Score 

95.3 65.3 86.6 83.3 78.5 

N= 86 71 70 4,078 54,400 

646GC Monaca 88.1 78.3 85.9 

 N= 76 82 77 

646GD Washington 76.9 81.5 84.7 

N= 79 79 88 

Figure 4. Outpatient Overall Quality 

Both Monaca and Washington CBOC scores were below the parent facility for “overall 

quality” for the 2nd and 4th Qtrs; however, both CBOCs equaled or exceeded the VHA 

target score of 77 percent. 

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) 

646 Pittsburgh Mean 

Score 

77.3 72.5 77.6 85 77.3 

 N= 

86 76 72 4,217 55,407 

646GC Monaca 94.4 95.2 94.3 

 N= 81 89 85 

646GD Washington 95.3 85 89.2 

N= 83 79 94 

Figure 5. Provider Wait Times 

Both CBOCs’ “provider wait times” indicator exceeded the parent facility in all quarters 

and met the VHA’s target score of 77 percent. 

VA Office of Inspector General 11 
CBOC Reviews: Lockport and Olean, Monaca and Washington, Berwick and Sayre, and Somerset 

CBOC Contract 

Monaca CBOC 

The contract for the Monaca CBOC is administered through the VA Pittsburgh HCS for 

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

care for all eligible veterans in VISN 4. Contracted services with Valor Healthcare Inc. 

began on November 1, 2007, and with option years extending through October 31, 2012. 

Their current contract was administered under option year 1 for the period November 1, 

2008, through October 31, 2009. The contract terms state that the CBOC will have (1) a 

Pennsylvania licensed physician to serve as medical director and (2) other primary care 

providers to include PAs and nurse practitioners. There were 3.0 FTE primary care 

providers for the1st Qtr, FY 2009. The contractor was compensated by the number of 

enrollees at a monthly capitated rate per enrollee. The CBOC had 4,367 unique primary 

medical care enrollees with 16,062 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 VA 

HCS 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 and found them consistent with supporting documentation and 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. 

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 4,735 enrollees billed on the December 2008 invoice was compared to 

dates of services rendered as reported in the Veterans Health Information Systems 

and Technology Architecture (VistA) system. 

• The tests resulted in identifying 457 enrollees billed to the VA who had not 

received any services at the CBOC for the period December 1, 2007, through 

December 31, 2008. 

• The contract with this CBOC specifically states under the clause, “Disenrollment,” 

that disenrollment occurs when the enrollee receives no further care from the 

CBOC within 1 year of last visit. 

• A more detailed analysis of 25 of the 457 enrollees noted the following: 

o 9 of 25 enrollees were deceased, one as early as February 2007. 

VA Office of Inspector General 12 
CBOC Reviews: Lockport and Olean, Monaca and Washington, Berwick and Sayre, and Somerset 

o Some enrollees appeared to have transferred to the HCS but continued to be 

billed by the contractor. 

• The overcharges for December 2008 are approximately $15,000. The HCS must 

analyze prior month billings to determine the total scope of overcharges 

attributable to contractor billings for enrollees who had not received services 

within the last 12 months. 

• The invoiced monthly capitated rate per enrollee (effective November 1, 2008) 

was $1.04 greater than the originally contracted rate. The $1.04 per enrollee was 

added for additional services which was agreed to by Valor Healthcare Inc. and 

the HCS. As of the date of this report, there has been no formal signed contract or 

addendum to reflect this agreement. 

Recommendation 6: We recommended that the VISN 4 Director ensure that the VA 

Pittsburgh HCS Director recovers the overcharges from the contractor for the Monaca 

CBOC and that future invoices are verified for compliance with contract provisions. 

Additionally, the VA Pittsburgh VA HCS Director should formalize the contractual 

agreement with the contractor regarding the “Point of Care” addendum. 

The VISN and HCS Directors concurred with our finding and recommendation. A bill of 

collection has been initiated to recover overcharges from the contractor. A prospective 

automated query has been developed which validates 100 percent of the invoices 

submitted by all CBOC vendors. The contractual agreement for the Monaca CBOC is 

being modified to address the “Point of Care” amendment. The improvement plans are 

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

Washington CBOC 

The contract for the Washington CBOC is administered through the VA Pittsburgh HCS 

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

care for all eligible veterans in VISN 4. Contracted services with Magnum Medical Joint 

Venture began on March 1, 2005, with option years extending through February 28, 

2010. Their current contract was administered under option year 3 for the period 

March 1, 2008, through February 28, 2009. The contract terms state that the CBOC will 

have (1) a Pennsylvania licensed physician to serve as medical director and (2) other 

primary care providers to include PAs and nurse practitioners. There were 4.6 FTE 

primary care providers for the 1st Qtr, FY 2009. The contractor was compensated by the 

number of enrollees at a monthly capitated rate per enrollee. The CBOC had 4,850 

unique primary medical care enrollees with 17,948 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 VA 

HCS and contractor personnel. Our review focused on documents and records for the 

VA Office of Inspector General 13 
CBOC Reviews: Lockport and Olean, Monaca and Washington, Berwick and Sayre, and Somerset 

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

of enrollees and found them consistent with supporting documentation and 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: 

• Our review of the contractor invoices for the period October through December 

2008 disclosed that no enrollees were removed from the invoices due to death or 

transfers to other facilities. Inquiries with the COTR revealed that the HCS failed 

to notify the contractor of deaths and disenrollments since April 2008 which 

resulted in overcharges to the HCS. 

• The estimated overcharges for the period May 2008 through June 2009 cannot be 

quantified as of the date of this report. Subsequent to our inquiries, the COTR has 

completed credit memos for 2 of 14 months which resulted in approximately 

$1,000 in credits being issued to the contractor. 

Recommendation 7: We recommended that the VISN 4 Director ensure that the VA 

Pittsburgh HCS Director recovers the overcharges from the Washington CBOC 

contractor and that future invoices are verified for compliance with contract provisions. 

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

prospective automated query has been developed which validates 100 percent of the 

invoices submitted by all of the CBOC vendors. Bill of collection actions will be taken 

for overcharges. The improvement plans are acceptable, and we will follow up on the 

planned actions until they are completed. 

VA Office of Inspector General 14 
CBOC Reviews: Lockport and Olean, Monaca and Washington, Berwick and Sayre, and Somerset 

VA Office of Inspector General 15 

C. VISN 4, Wilkes-Barre VAMC – Berwick and Sayre 

Quality of Care Measures 

The Berwick and Sayre CBOC’s quality measures scores equaled or exceeded their 

parent facility’s quality measures scores and the VHA target goals with the exception of 

the following indicator: DM lipid profile. The Berwick CBOC scored slightly lower on 

the DM lipid profile than Sayre CBOC and did not meet the VHA target goal. (See 

Appendix K.) 

Credentialing and Privileging 

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

the Berwick CBOC and five providers and four nurses at the Sayre CBOC. All providers 

possessed a full, active, current, and unrestricted license. However, we identified the 

following areas that needed improvement: 

Credentialing 

VHA policy5

 requires that the chief of the clinical service assign a collaborating 

physician to monitor and evaluate the clinical activities of PAs. We found 

inconsistencies in the monitoring of two PAs’ performance at the Berwick CBOC. We 

reviewed the C&P files of the PAs and did not find evidence that their performance was 

monitored consistently by the designated collaborating physician identified in their 

Scopes of Practice.6

 

Staff Competencies 

Nursing Staff. The establishment of competencies is the assurance that an individual has 

received the appropriate training and has demonstrated the skill level required to 

independently and appropriately perform an assigned task. At the Berwick CBOC, the 

nursing competencies are examined and approved by an administrator, who is not a 

clinician. 

At the Sayre CBOC, nurses routinely dispensed prosthetic adaptive devices such as 

crutches and walkers to patients and trained the patients in the use of the devices. At the 

time of our visit, we found no evidence of training and/or competency evaluation to 

perform this task. 

 

5

 VHA Directive 2004-029 Utilization of Physician Assistants, July 2, 2004. 6

 “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: Lockport and Olean, Monaca and Washington, Berwick and Sayre, and Somerset 

VA Office of Inspector General 16 

Radiology Technologist. The radiology technologist assigned to the Sayre CBOC, in 

addition to radiograph studies, performed other assigned duties which included, 

accessioning7

 laboratory specimens and Holter Monitor8 application. We reviewed the 

training folder of the radiology technologist and did not find evidence of demonstrated 

competency related to Holter Monitor application. 

Recommendation 8. We recommended that the VISN 4 Director ensure that the WilkesBarre VAMC Director requires that the Berwick CBOC PAs are consistently monitored 

and evaluated by the collaborative physician and that the results of the evaluations are 

used during the re-credentialing process. 

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

administrative officer at Berwick will track collaborating physician’s monitoring of PAs 

performance and contact the Associate Chief of Staff when chart reviews are not 

completed as required. 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 4 Director ensure that the WilkesBarre VAMC Director requires that clinical competencies of Berwick and Sayre CBOC 

staff are monitored by the appropriate discipline. 

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

clinical competencies will be monitored by the nurse supervisor. The improvement plans 

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

Recommendation 10. We recommended that the VISN 4 Director ensure that the 

Wilkes-Barre VAMC Director requires that Berwick and Sayre CBOC staff are trained 

and evaluated and that the competencies are documented. 

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

service chief of each specialty will be responsible for the proficiency and competency of 

CBOC staff members. 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 

 

7

 Preparing specimens for analysis such as placing blood tube in a centrifuge or packing specimens for transport to 

parent facility. 

8

 A portable continuous electrocardiographic recorder. 
CBOC Reviews: Lockport and Olean, Monaca and Washington, Berwick and Sayre, and Somerset 

VA Office of Inspector General 17 

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

improvement: 

Personally Identifiable Information 

According to Health Insurance Portability and Accountability Act (HIPAA)9 regulations, 

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

Berwick CBOC physician’s room had built-in wall-to-wall open shelves that contained 

radiological exams (x-rays), dated from 1999 to 2007. 

The x-ray jackets contained personally identifiable information (PII) such as the veteran’s 

name and SSN and procedure performed. In some cases, the folders contained the x-ray 

reports. The reports and films must be maintained according to the provisions of Records 

Control Schedule 10-1 (RCS 10-1) and the National Archives and Records 

Administration. Reports are part of the patient’s medical record, and as such must be 

kept for 75 years. X-ray films should be destroyed 5 years after the date of last exposure 

or 10 years after separation from the military, whichever is later. 

Across the room from the built-in shelves is a wall-to-wall window. The window was 

covered with conventional mini-blinds. When the blinds are open, the files were visible 

to the parking area; and the building did not have an intruder alarm. Hard copy PII 

should be maintained in a locked desk, cabinet, or container when no security is present. 

Panic Alarms 

The Berwick CBOC provides MH services but did not have panic alarms. The staff 

described several processes utilized to ensure a safe environment and a rapid response to 

a MH emergency. These processes included arranging office furniture for easy access to 

the clinic corridors, ongoing monitoring of the flow of patients during the clinic hours, 

and placing all items that could be potentially used as a weapon in closed drawers. 

Handicap Access 

Ramps to the front doors at both CBOCs allowed patients in wheelchairs or with other 

assistive devices to independently maneuver to the CBOC doors. However, the Berwick 

CBOC was not equipped with an automatic door opener or door bell to assist patients to 

access the building. The staff indicated that patients who required assistance were 

usually escorted to their appointments, and the escorts would open the door so the patient 

could gain entry. 

 

9 The Health Insurance Portability and Accountability Act of 1996, privacy rule’s protection of the privacy of 

individually identifiable health information.
CBOC Reviews: Lockport and Olean, Monaca and Washington, Berwick and Sayre, and Somerset 

Equipment Maintenance 

The Berwick CBOC staff performs radiological examinations using a bladder scanner. 

We found documentation (preventive maintenance label) that the bladder scanner had not 

undergone preventive maintenance since 2006. 

When we inquired about the maintenance history, we were told that a manual calibration 

was completed onsite and this met the intent of manufacturer’s preventive maintenance 

guidelines. We requested that staff obtain written verification of this information from 

the manufacturer. The manufacturer did not confirm the process used at the CBOC but 

agreed to forward the appropriate guidelines. The preventive maintenance is the 

responsibility of the contractor. 

Recommendation 11. We recommended that the VISN 4 Director ensure that the 

Wilkes-Barre VAMC Director requires that appropriate actions be taken to secure and 

protect health records at the Berwick CBOC. 

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

radiology films from the Berwick CBOC are now stored at the VAMC. The 

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

they are completed. 

Recommendation 12. We recommended that the VISN 4 Director ensure that the 

Wilkes-Barre VAMC Director has a security risk assessment conducted and evaluates the 

assessment to determine appropriate measures to take at the Berwick CBOC. 

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

Wilkes-Barre VAMC is requiring installation of panic alarms at the Berwick CBOC, and 

the COTR has begun the negotiation process for the contract modification changes. 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 4 Director ensure that the 

Wilkes-Barre VAMC Director requires that modifications to the entrance doors be made 

at the Berwick CBOC in order to improve access for disabled veterans. 

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

Berwick CBOC is developing a plan to install an automated door, and the COTR will 

monitor the project until completion. The improvement plans are acceptable, and we will 

follow up on the planned actions until they are completed. 

Recommendation 14. We recommended that the VISN 4 Director ensure that the 

Wilkes-Barre VAMC Director requires that the Berwick CBOC adheres to the 

manufacturer’s equipment (Bladder Scanner) maintenance requirement. 

VA Office of Inspector General 18 
CBOC Reviews: Lockport and Olean, Monaca and Washington, Berwick and Sayre, and Somerset 

VA Office of Inspector General 19 

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

maintenance log has been established, and the COTR will continue to monitor for 

compliance. 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 are handled, including MH emergencies. Both CBOCs had policies 

that outlined management of medical and MH emergencies, and staff were able to 

articulate the principles underlying the policies. However, we found the following areas 

that needed improvement: 

Medication Management 

The Sayre CBOC had a stock of medications located in a locked cabinet. The CBOC 

nurses and a pharmacy technician dispense medications for short-term management of 

“immediate” medical conditions from the locked cabinet. This process did not include 

the direct control of a clinical pharmacist as required by VHA policy.10 The managers 

told us that a licensed pharmacist reviews the prescriptions and medication orders within 

48 hours. 

Reusable Medical Equipment 

The Berwick CBOC performs suturing, removal of foreign objects, cast application, and 

other urgent non-operative procedures using reusable medical equipment (RME). The 

staff reported that the RME, such as basins, tweezers, nail clippers, and speculums, were 

manually scrubbed with a copper brush. The equipment was cleaned with soapy water 

and alcohol prior to flash11 sterilization. Our examination of the brush used to clean the 

instruments revealed the brush bristles were worn out and the wooden handle was stained 

(residual from copper bristles). The disinfectant container was also dirty. 

The safe performance of procedures involving reprocessing12 of RME requires a 

systematic process including initial training of personnel; proper setup, use, and 

reprocessing for each occurrence; annual validation of competencies; and quality 

oversight. At the time of our visit, Berwick CBOC did not have written guidelines for 

reprocessing RME. 

 

10 VHA Handbook 1108.05, Outpatient Pharmacy Services, May 30, 2006. 11 A steam process to sterilize instruments. Time for sterilization is dependent upon the instrument to be sterilized. 

12 Reprocessing is the cleaning, disinfection, sterilization, and preparation of equipment to full readiness for its 

subsequent use. 
CBOC Reviews: Lockport and Olean, Monaca and Washington, Berwick and Sayre, and Somerset 

Recommendation 15. We recommended that the VISN 4 Director ensure that the 

Wilkes-Barre VAMC Director examines the existing processes to ensure that 

pharmaceuticals at the Sayre CBOC are dispensed according to VHA policy. 

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

process has been established that only providers will dispense medications to the patients 

at the Sayre CBOC. The improvement plans are acceptable, and we will follow up on the 

planned actions until they are completed. 

Recommendation 16. We recommended that the VISN 4 Director ensure that the 

Wilkes-Barre VAMC Director have the Berwick CBOC properly reprocess RME. 

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

Berwick CBOC has discontinued use of RME and is now using only disposable 

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

actions until they are completed. 

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) 

693 WilkesBarre Mean 

Score 

74.3 78.8 74.8 83.3 78.5 

N= 84 86 82 4,078 54,400 

693GF Berwick 66.1 75.7 60 

N= 89 79 75 

693GA Sayre 80.6 79 82.4 

N= 59 69 75 

Figure 6. Outpatient Overall Quality 

The Sayre CBOC exceeded the parent facility’s SHEP scores, while the Berwick CBOC 

failed to meet VHA target goal of 77 percent for all three quarters. We were told the low 

scores were attributed to staffing and parking. To address the issues, the contractor hired 

new providers; and the parent facility assigned an Associate Chief, Ambulatory Care, to 

provide additional oversight. Managers stated the staff were making efforts to improve 

customer relations. Parking spaces were also enhanced. 

VA Office of Inspector General 20 
CBOC Reviews: Lockport and Olean, Monaca and Washington, Berwick and Sayre, and Somerset 

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) 

693 WilkesBarre Mean 

Score 

90.1 86.8 83.6 85 77.3 

 N= 88 86 81 4,217 55,407 

693GF Berwick 79.9 76.8 66.9 

N= 94 82 74 

693GA Sayre 81 88.1 86.9 

N= 64 76 76 

Figure 7. Provider Wait Times 

The Berwick CBOC failed to meet the VHA target goal of 77 in the 2nd Qtr but made 

significant improvements during the 3rd and 4th Qtrs. 

CBOC Contract 

Berwick CBOC 

The contract for the Berwick CBOC is administered through the Wilkes-Barre VAMC for 

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

care for all eligible veterans in VISN 4. Contracted services with Valor Healthcare Inc. 

began on November 1, 2007, and with option years extended through October 31, 2012. 

Their current contract was administered under option year 1 for the period November 1, 

2008, through October 31, 2009. The contract terms state that the CBOC will have (1) a 

Pennsylvania-licensed physician to serve as medical director, and (2) other primary care 

providers to include PAs and nurse practitioners. There were 2.02 FTE primary care 

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

enrollees at a monthly capitated rate per enrollee. The CBOC had 2,155 unique primary 

medical care enrollees with 6,134 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 

Wilkes-Barre 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 and found them consistent with supporting 

documentation and 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. 

VA Office of Inspector General 21 
CBOC Reviews: Lockport and Olean, Monaca and Washington, Berwick and Sayre, and Somerset 

We noted the following: 

• Analytical tests performed on the December 2008 invoice resulted in identifying 

16 errors in enrollee SSNs. The SSNs reported on the invoice did not match the 

SSN of the enrollee’s data in VistA by one or more digits. 

• These discrepancies may impact the COTR’s ability to reconcile invoices with 

patient records in VistA. 

Recommendation 17: We recommended that the VISN 4 Director ensure that the 

Wilkes-Barre VAMC Director discuss these issues with the contractor to ensure that the 

VAMC is receiving accurate and complete information on Berwick CBOC contractor 

billings. 

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

review has been implemented to ensure there is accurate and complete information on 

Berwick CBOC contractor invoices. The improvement plans are acceptable, and we will 

follow up on the planned actions until they are completed. 

VA Office of Inspector General 22 
CBOC Reviews: Lockport and Olean, Monaca and Washington, Berwick and Sayre, and Somerset 

D. VISN 9, Lexington VAMC – Somerset 

Quality of Care Measures 

The Somerset CBOC scored equally or exceeded the parent facility’s quality measure 

scores with the exception of screening for PTSD. Both the Somerset CBOC and parent 

facility met the VHA target goals. (See Appendix L.)

Credentialing and Privileging 

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

at the Somerset CBOC. All providers and nurses possessed a full, active, current and 

unrestricted license; and education verification and background checks were completed in 

accordance to policy. Performance Improvement provider-specific data was maintained 

on all providers and included in the reprivileging process. Overall, we found that the 

C&P process, including background checks, for providers and nurses at the CBOCs is 

done in accordance to VHA policies. 

Environment and Emergency Management 

Environment of Care

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

control, and general maintenance. Somerset CBOC met all standards, and the 

environment was clean and safe. 

Emergency Management

The local Emergency Operation Plan described management of cardiac arrest at the 

CBOC; however, the guidelines did not include the use of an AED. Additionally, the 

plan did not include management of medical emergencies such as seizures or severe 

hypoglycemic events or MH emergencies. The management of MH emergencies was 

addressed in the parent facility’s local policies. Staff articulated responses that accurately 

reflected the local emergency response guidelines; however, they did not know where the 

written documents for managing MH emergencies were located. 

Recommendation 18. We recommended that the VISN 9 Director ensure that the 

Lexington VAMC Director requires that the Somerset CBOC develop a local policy for 

medical and MH emergencies that reflects the current practices at the CBOC. 

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

Emergency Operation Procedure Manual has been amended to include the use of an 

AED, and the Service Emergency Contingency plan has been updated to include 

VA Office of Inspector General 23 
CBOC Reviews: Lockport and Olean, Monaca and Washington, Berwick and Sayre, and Somerset 

VA Office of Inspector General 24 

management of medical emergencies. 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 8 and 9. 

Trip Pak Report - STA5 Level 

Patient Perceptions of Care 

2008 SHEP Performance Measures 

YTD Through September 2008 

Performance 

Measure (SHEP 

question #) 

Station 

Number 

Facility 

Name 

Data 

Type 

FY08 

Qtr 4 

FY08 

Qtr 3 

FY08 

Qtr 2 

VISN 

FY08, 

Qtr 4 

National 

FY08, 

Qtr 4 

(Q56) - Outpatients 

(percent Very Good, 

Excellent) 

596 Lexington Mean 

Score 

76.8 72.6 68.9 78.8 78.5 

N= 79 82 84 2,650 54,400 

596GASomerset 

79.2 75.7 77.5 

 N= 75 90 77 

Figure 8. Outpatient Overall Quality 

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) 

596 Lexington Mean 

Score 

80.9 83.1 76.4 70.2 77.3 

 N= 77 81 83 2,682 55,407 

596GASomerset 

90 81.3 80 

 N= 77 89 78 

Figure 9. Provider Wait Times

The Somerset CBOC exceeded its parent facility’s “overall quality” SHEP scores. The 

CBOC met the target goal of 77 for all quarters. The Somerset CBOC made continual 

improvement each quarter. By the 4th Qtr, their “provider wait times” score improved 

from 80 to 90 percent. 
CBOC Reviews: Lockport and Olean, Monaca and Washington, Berwick and Sayre, and Somerset 

Appendix A 

VISN 2 Director Comments 

VA Office of Inspector General 25 

Department of 

Veterans Affairs Memorandum

Date: September 1, 2009 

From: Director, Veterans Integrated Service Network (10N2) 

Subject: Healthcare Inspection – CBOC Reviews: Lockport and 

Olean, NY

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

Healthcare Inspections (54F) 

VISN 2 concurs with the Inspection findings and recommendations. 
CBOC Reviews: Lockport and Olean, Monaca and Washington, Berwick and Sayre, and Somerset 

Appendix B 

VA Western New York HCS Director Comments 

VA Office of Inspector General 26 

Department of 

Veterans Affairs Memorandum

Date: September 1, 2009 

From: Director, VA Western New York HCS (528/00) 

Subject: Healthcare Inspection – CBOC Reviews: Lockport and 

Olean, NY

To: Director, Veterans Integrated Service Network (10N2) 

We concur with your findings and recommendations. 
CBOC Reviews: Lockport and Olean, Monaca and Washington, Berwick and Sayre, and Somerset 

VA Office of Inspector General 27 

VA Western New York HCS 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 2 Director ensure 

that the VA Western New York HCS Director requires that contract 

providers at the Lockport CBOC are privileged according to policy. 

Concur Target Completion Date: 11/15/09

According to VHA Handbook 1100.19; C&P will re-credential & privilege 

all VAWNYHS contract CBOC providers to reflect one year renewal 

intervals in coordination with contract renewal. This process will be done 

upon the next renewal of each individual provider’s C&P expiration and 

then expiration of contract dates. 

Recommendation 2. We recommended that the VISN 2 Director ensure 

that the VA Western New York HCS Director implements the 

recommendation to install a panic alarm system at the Olean CBOC. 

 Concur Target Completion Date: 11/15/09

A mechanism will be installed in the Olean CBOC that will be used to alert 

employees that a crisis situation is occuring and that action needs to be 

taken. Additionally, a standard operating procedure will be developed to 

specify what actions should be taken in response to an alert. 
CBOC Reviews: Lockport and Olean, Monaca and Washington, Berwick and Sayre, and Somerset

Appendix C 

VISN 4 Director Comments 

VA Office of Inspector General 28 

Department of 

Veterans Affairs Memorandum

Date: September 8, 2009 

From: Director, Veterans Integrated Service Network (10N4) 

Subject: Healthcare Inspection – CBOC Reviews: Monaca and 

Washington, PA; and Berwick and Sayre, PA

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

Healthcare Inspections (54F) 

THRU: Director, VHA Management Review Service 

(10B5) 

1. I have reviewed the response to the draft Healthcare Inspection-CBOC Review 

report provided by the Pittsburgh VA Healthcare System and Wilkes-Barre VA 

Medical Center and concur with their responses. I am submitting the action plans 

to your office as requested. 

2. If you have any questions or require additional information, please contact 

Barbara Forsha, VISN QMO at 412-822-3290. 

 (original signed by:) 

MICHAEL E. MORELAND, FACHE 

Attachment 

 
CBOC Reviews: Lockport and Olean, Monaca and Washington, Berwick and Sayre, and Somerset

Appendix D 

VA Pittsburgh HCS Director Comments

VA Office of Inspector General 29 

Department of 

Veterans Affairs Memorandum

Date: September 3, 2009 

From: Director, VA Pittsburgh HCS (646/00) 

Subject: Healthcare Inspection – CBOC Reviews: Monaca and 

Washington, PA

To: Director, Veterans Integrated Service Network (10N4) 

 1. The following Director’s comments are submitted in 

response to the recommendations in the Office of the 

Inspector General report of the CBOC review for Monaca 

and Washington, Pennsylvania. 

 2. Please do not hesitate to contact the Quality 

Management Director at 412-360-1858 if there are any 

questions. 

 
CBOC Reviews: Lockport and Olean, Monaca and Washington, Berwick and Sayre, and Somerset

VA Pittsburgh HCS 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 3. We recommended that the VISN 4 Director ensure 

that the VA Pittsburgh HCS Director requires that the Washington CBOC 

background checks are completed in accordance with VHA requirements. 

Concur Target Completion Date: Completion of SIC Relocation

Since May, 2008 a new system was created to insure that background 

checks were completed in accordance with VHA requirements. No 

deficiencies were identified since that time. The Washington CBOC 

provider was adjudicated in 2007. Due to the relocation of the Security 

Investigation Center (SIC) all efforts to date have been unsuccessful in 

obtaining a copy of the initial results. As soon as the relocation has been 

completed the required copies will be obtained and filed. 

Recommendation 4. We recommended that the VISN 4 Director ensure 

that the VA Pittsburgh HCS Director requires auditory privacy be 

maintained during the check-in process at the Washington CBOC. 

Concur Target Completion Date: Completed 

The waiting area at the Washington CBOC has been reconfigured which 

moved the seating area to the farthest part of the room away from the 

check- in window. The statement of work for all future CBOC contracts 

will contain an auditory privacy requirement for the registration area. 

Recommendation 5. We recommended that the VISN 4 Director ensure 

that the VA Pittsburgh HCS Director requires that Monaca CBOC have an 

emergency management plan that includes emergency response to all MH 

emergencies. 

Concur Target Completion Date: Completed

The Emergency Plan for the Monaca CBOC has been revised to include the 

procedure for when veterans are assessed as being at harm to self or others 

VA Office of Inspector General 30 
CBOC Reviews: Lockport and Olean, Monaca and Washington, Berwick and Sayre, and Somerset

VA Office of Inspector General 31 

to include suicide and violent behavior. All staff at the CBOC was oriented 

to the changes in the plan and was provided a copy of the revised 

document. 

Recommendation 6. We recommended that the VISN 4 Director ensure 

that the VA Pittsburgh HCS Director recovers the overcharges from the 

contractor for the Monaca CBOC and that future invoices are verified for 

compliance with contract provisions. Additionally, the VA Pittsburgh VA 

HCS Director should formalize the contractual agreement with the 

contractor regarding the “Point of Care” addendum. 

Concur Target Completion Date: Completed

A prospective automated query has been developed which validates 100% 

of the invoices submitted by all CBOC vendors. A Standard Operating 

Procedure has been developed which details the process for validating and 

certifying CBOC contractor invoices. Bill of collection, to the contractor, 

initiated September 2, 2009 for the overcharges to the contractor. In 

addition, a 100% retrospective review of Monaca invoices since the 

contract was awarded was initiated. A twelve month retrospective review of 

the invoices for the other CBOC vendors was initiated. Bill of collection 

actions will be taken as might be warranted by the outcomes of these 

reviews. The contractual agreement for the Monaca CBOC is being 

modified to address the point of care amendment. 

Recommendation 7. We recommended that the VISN 4 Director ensure 

that the VA Pittsburgh HCS Director recovers the overcharges from the 

Washington CBOC contractor and that future invoices are verified for 

compliance with contract provisions. 

Concur Target Completion Date: September 11, 2009

A prospective automated query has been developed which validates 100% 

of the invoices submitted by all of the CBOC vendors. Since the 

Washington CBOC vendor does not have an automated invoicing system 

medical center staff are applying the automated query in a retrospective 

review of the last twelve months of Washington CBOC invoices. Bill of 

collection actions will be taken for any amount of overcharges as identified 

through this review. 
CBOC Reviews: Lockport and Olean, Monaca and Washington, Berwick and Sayre, and Somerset

Appendix E 

Wilkes-Barre VAMC Director Comments 

VA Office of Inspector General 32 

Department of 

Veterans Affairs Memorandum

Date: August 31, 2009 

From: Director, Wilkes-Barre VAMC (693/00) 

Subject: Healthcare Inspection – CBOC Reviews: Berwick and Sayre, 

PA

To: Director, Veterans Integrated Service Network (10N4) 

1. After reviewing the report, I concur with the findings identified. 

2. The Wilkes-Barre VA Medical Center has developed and 

implemented the following action plans with designated 

anticipated completion dates. 

3. Please contact Yvonne Bohlander at 570.824.3521, extension 

7974, or myself at 570.821.7204 with any questions or concerns 

regarding the following action plans. 

(original signed by:) 

JANICE M. BOSS, MS, CHE 
CBOC Reviews: Lockport and Olean, Monaca and Washington, Berwick and Sayre, and Somerset

VA Office of Inspector General 33 

Wilkes-Barre 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 4 Director ensure 

that the Wilkes-Barre VAMC Director requires that the Berwick CBOC 

PAs are consistently monitored and evaluated by the collaborative 

physician and that the results of the evaluations are used during the recredentialing process. 

Concur Target Completion Date: August 1, 2009 (completed)

Administrative Officer for Berwick will track this and if chart reviews are 

not returned she will contact the supervising providers to assure that they 

are completed. Associate Chief of Staff for Primary Care will be notified if 

this is not completed after reminder call from Administrative Officer. 

Recommendation 9. We recommended that the VISN 4 Director ensure 

that the Wilkes-Barre VAMC Director requires that clinical competencies 

of Berwick and Sayre CBOC staff are monitored by the appropriate 

discipline. 

Concur Target Completion Date: October 1, 2009

Organization charts have been adjusted so that service chief for each 

specialty is responsible for the proficiency and competency of the 

employee. These have been submitted and are in the approval stage. 

Berwick nursing is to be monitored by nurse supervisor as designated by 

Nurse Executive. 

Recommendation 10. We recommended that the VISN 4 Director ensure 

that the Wilkes-Barre VAMC Director requires that Berwick and Sayre 

CBOC staff are trained and evaluated and that the competencies are 

documented. 

Concur Target Completion Date: October 1, 2009
CBOC Reviews: Lockport and Olean, Monaca and Washington, Berwick and Sayre, and Somerset

VA Office of Inspector General 34 

Organization charts have been adjusted so that the service chief of that 

specialty is responsible for the proficiency and competency. These have 

been submitted and are in the approval stage. The primary care providers 

currently have the same ongoing professional evaluations and competencies 

at both Wilkes Barre and all CBOCs (including Berwick). Berwick nursing 

is to be monitored by nurse supervisor as designated by Nurse Executive. 

Recommendation 11. We recommended that the VISN 4 Director ensure 

that the Wilkes-Barre VAMC Director requires that appropriate actions be 

taken to secure and protect health records at the Berwick CBOC. 

Concur Target Completion Date: August 27, 2009 (completed)

All radiology films from the Berwick CBOC are now stored at the Medical 

Center. 

Recommendation 12. We recommended that the VISN 4 Director ensure 

that the Wilkes-Barre VAMC Director has a security risk assessment 

conducted and evaluates the assessment to determine appropriate measures 

to take at the Berwick CBOC. 

Concur Target Completion Date: October 1, 2009, for the receipt 

of quotes 

VA is requiring installation of panic alarm(s) at the Berwick CBOC. The 

Contracting Officer has begun the negotiation process for the contract 

modification changes. The COTR will continue to monitor for full 

completion. 

Recommendation 13. We recommended that the VISN 4 Director ensure 

that the Wilkes-Barre VAMC Director requires that modifications to the 

entrance doors be made at the Berwick CBOC in order to improve access 

for disabled veterans. 

Concur Target Completion Date: October 1, 2009 (After 

ELT approval and receipt of quotes)

The Berwick CBOC is developing a plan to install automated doors. The 

Contracting Officer has begun the negotiation process for this VA-directed 

and VA-paid modification to the contract. The Contracting Officer 

recommends the Berwick Clinic be allowed to choose the vendor to 

complete the work. This ultimately relieves the VA from any subsequent 
CBOC Reviews: Lockport and Olean, Monaca and Washington, Berwick and Sayre, and Somerset

VA Office of Inspector General 35 

problems that may be incurred as a result of the modification. The COTR 

will continue to monitor for full completion. 

Recommendation 14. We recommended that the VISN 4 Director ensure 

that the Wilkes-Barre VAMC Director requires that the Berwick CBOC 

adheres to the manufacturer’s equipment maintenance requirement. 

Concur Target Completion Date: August 31, 2009 (completed)

A maintenance check log has been established on an ongoing basis. The 

COTR will continue to monitor for compliance. 

Recommendation 15. We recommended that the VISN 4 Director ensure 

that the Wilkes-Barre VAMC Director examines the existing processes to 

ensure that pharmaceuticals at the Sayre CBOC are dispensed according to 

VHA policy. 

Concur Target Completion Date: July 31, 2009 (completed)

There are small amounts of a few medications that would be needed by 

patients urgently. The new process is the provider, and only the provider, 

accesses medications and dispenses to the patients at Sayre. 

Recommendation 16. We recommended that the VISN 4 Director ensure 

that the Wilkes-Barre VAMC Director have the Berwick CBOC properly 

reprocess RME. 

Concur Target Completion Date: August 24, 2009 (completed)

Berwick has discontinued use of the reusable equipment and is now using 

disposable equipment only. 

Recommendation 17. We recommended that the VISN 4 Director ensure 

that the Wilkes-Barre VAMC Director discuss these issues with the 

contractor to ensure that the VAMC is receiving accurate and complete 

information on Berwick CBOC contractor billings. 

Concur Target Completion Date: August 24, 2009 (completed)

All invoices are now being reviewed to validate correct Social Security 

numbers. The review will also ascertain if any patients were not seen 

within one year and if any patients are deceased. 
CBOC Reviews: Lockport and Olean, Monaca and Washington, Berwick and Sayre, and Somerset 

Appendix F 

VISN 9 Director Comments 

VA Office of Inspector General 36 

Department of 

Veterans Affairs Memorandum

Date: September 1, 2009 

From: Director, Veterans Integrated Service Network (10N9) 

Subject: Healthcare Inspection – CBOC Review: Somerset, KY 

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

Healthcare Inspections (54F) 

1. I concur with the Office of Inspector General finding 

regarding our Somerset Community Based Outpatient Clinic 

as well as the action plan developed by the facility. 

2. If you have questions or require additional information from 

the Network, please do not hesitate to contact Pamela Kelly, 

Staff Assistant to the Network Director at 615-695-2205 or me 

at 615-695-2206. 

 (original signed by:) 

 John Dandridge, Jr. 

 
CBOC Reviews: Lockport and Olean, Monaca and Washington, Berwick and Sayre, and Somerset

Appendix G 

Lexington VAMC Director Comments 

VA Office of Inspector General 37 

Department of 

Veterans Affairs Memorandum

Date: August 25, 2009 

From: Director, Lexington VAMC (596/00) 

Subject: Healthcare Inspection – CBOC Review: Somerset, KY 

To: Director, Veterans Integrated Service Network (10N9) 

We concur with the Office of Inspector General finding 

regarding our Somerset Community Based Outpatient 

Clinic and are taking the necessary action to enhance our 

patient management policies and procedures to more 

clearly outline our approaches to managing medical and 

mental health emergencies in the clinic. We appreciate 

the manner in which the review was conducted as well as 

the very positive feedback about the clinic made by the 

reviewers while they were on site. 

 (original signed by:) 

Sandy J. Nielsen, FACHE 
CBOC Reviews: Lockport and Olean, Monaca and Washington, Berwick and Sayre, and Somerset

Lexington 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 18. We recommended that the VISN 9 Director ensure 

that the Lexington VAMC Director requires that the Somerset CBOC 

develop a local policy for medical and MH emergencies that reflects the 

current practices at the CBOC. 

Concur Target Completion Date: 9/30/09

In concert with the OIG reviewers’ on site guidance, three key actions are 

being taken in response to this recommendation: 

(1) The section on cardiac arrest in the Emergency Operation Procedure 

Manual has been amended to include the provision that the Automatic 

External Defibrillator (AED) will be retrieved and used by staff 

performing CPR. 

STATUS: Complete 

(2) The section on cardiac arrest in the Service Emergency Contingency 

plan has been updated to include the following provisions: (a) if a 

medical emergency situation arises at the clinic, the clinical staff are to 

be alerted immediately; (b) if a Code Blue is called, the administrative 

staff will call 911; (c) the AED will be retrieved and used by trained 

clinical staff performing CPR; (d) clinical management of medical 

emergencies other than cardiac arrest will be addressed following 

standard operating procedures for specific higher risk conditions. 

STATUS: Complete 

(3) Standard operating procedures are being developed at the CBOC to 

address clinical management of those higher risk conditions identified 

by the OIG reviewer (seizures, hypoglycemia, and mental health 

emergencies). 

STATUS: In progress Target Completion Date: 9/30/09 

VA Office of Inspector General 38 
CBOC Reviews: Lockport and Olean, Monaca and Washington, Berwick and Sayre, and Somerset

Appendix H 

CBOC Characteristics 

CBOC Station Number CBOC Name Parent VA Specialty Care Cardiology  Dermatology Gastrointestinal Occupational Therapy Optometry Orthopedics Physical Therapy Podiatry 

528GK Lockport, NY Western NY HCS No No No No No No No No No 

528GR Olean, NY Western NY HCS No No No No No No No No No 

646GC Monaca, PA Pittsburgh HCS Yes No No No No No No No Yes 

646GD Washington, PA Pittsburgh HCS Yes No No No No No No No Yes 

693GF Berwick, PA Wilkes-Barre VAMC No No No No No No No No No 

693GA Sayre, PA Wilkes-Barre VAMC Yes No No No No No No No Yes 

596GA Somerset, KY Lexington 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 

528GK Lockport, NY Western NY HCS Yes No Yes Yes Yes Yes No

528GR Olean, NY Western NY HCS Yes No Yes Yes Yes Yes No

646GC Monaca, PA Pittsburgh HCS Yes Yes No Yes Yes Yes No

646GD Washington, PA Pittsburgh HCS Yes Yes No Yes Yes Yes No

693GF Berwick, PA Wilkes-Barre VAMC Yes No No Yes Yes No No

693GA Sayre, PA Wilkes-Barre VAMC Yes Yes No Yes Yes Yes No

596GA Somerset, KY Lexington VAMC Yes No No Yes Yes No No

 Note: Tele-nutrition is provided from another CBOC site to the Berwick, PA CBOC.

Onsite Services 

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

528GK Lockport, NY Western NY HCS Yes No Yes No No No No

528GR Olean, NY Western NY HCS Yes No No No No Yes Yes 

646GC Monaca, PA Pittsburgh HCS Yes No No No No Yes Yes 

646GD Washington, PA Pittsburgh HCS Yes No No No No Yes Yes 

693GF Berwick, PA Wilkes-Barre VAMC Yes No No Yes No Yes Yes 

693GA Sayre, PA Wilkes-Barre VAMC Yes No No Yes No Yes No 

596GA Somerset, KY Lexington VAMC Yes Yes No Yes Yes Yes Yes 

Mental Health Services

VA Office of Inspector General 39 
CBOC Reviews: Lockport and Olean, Monaca and Washington, Berwick and Sayre, and Somerset

CBOC Station Number CBOC Name Internal Medicine Primary Care Physician Nurse Practitioner Physician Assistant Registered Nurse LPN Psychologist Pharmacist Social Worker DietaryTechnician/ Technologists Administrative/ Clerical Other 

528GK Lockport, NY No Yes Yes No Yes Yes Yes Yes Yes Yes No Yes No

528GR Olean, NY No Yes Yes No Yes Yes No Yes Yes Yes No Yes No

646GC Monaca, PA No Yes No Yes Yes Yes No No Yes Yes Yes Yes No

646GD Washington, 

PA 

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

693GF Berwick, PA No Yes No Yes Yes Yes No No Yes No Yes Yes No

693GA Sayre, PA No Yes No Yes Yes No No No Yes Yes Yes Yes Yes 

596GA Somerset, KY Yes Yes Yes No Yes Yes No No Yes No No Yes No 

 Note: Sayre, PA also has a Psychiatrist.

Disciplines Present at the CBOC 

CBOC Station Number CBOC Name Parent VA Urban/Rural Miles to Parent Facility Bus Taxi Voluntary Services Tele-medicine 

528GK Lockport, NY Western NY HCS Urban 15 Yes Yes No No

528GR Olean, NY Western NY HCS Urban 76 Yes Yes No No

646GC Monaca, PA Pittsburgh HCS Urban 35 Yes Yes No No

646GD Washington, PA Pittsburgh HCS Urban 33 Yes Yes No No

693GF Berwick, PA Wilkes-Barre VAMC Rural 33 No Yes Yes No

693GA Sayre, PA Wilkes-Barre VAMC Rural 83 Yes Yes No No

596GA Somerset, KY Lexington VAMC Rural 74 No Yes Yes No

Type of Location, Availability of Public 

 Transportation, and Participation in Tele-medicine 

VA Office of Inspector General 40 
CBOC Reviews: Lockport and Olean, Monaca and Washington, Berwick and Sayre, and Somerset

Appendix I 

Quality of Care Measures 

VA Western New York HCS – Lockport and Olean 

Measure Facility 

Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 Percentage 

Hyperlipidemia 

Screen 

National 13,148 13,587 97 

528 Buffalo 100 107 93 

 528GK Lockport 28 30 93 

 528GR Olean 34 35 97 

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 

528 Buffalo 43 46 93 

528GK Lockport 50 50 100 

528GR Olean 45 45 100 

DM Foot Inspection, FY 2009 

 Measure Facility Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 Percentage 

DM - Outpatient Foot 

Pedal Pulses 

National 5,395 5,971 90 

528 Buffalo 43 46 93 

528GK Lockport 50 50 100 

528GR Olean 45 45 100 

Foot Pedal Pulses, FY 2009 

Sensory Exam 

DM - Outpatient - Foot 

Sensory Exam Using 

Monofilament 

National 5,266 5,951 88 

528 Buffalo 41 45 91 

528GK Lockport 50 50 100 

528GR Olean 44 45 98 

Foot Sensory, FY 2009 

VA Office of Inspector General 41 
CBOC Reviews: Lockport and Olean, Monaca and Washington, Berwick and Sayre, and Somerset

Measure Meets 

Target 

Facility Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 

Percentage 

DM – Retinal 

Eye Exam 

88 National 4,599 5,258 87 

88 528 Buffalo 35 39 90 

528GK Lockport 48 50 96 

528GR Olean 42 45 93 

Retinal Exam, FY 2009 

Measure Meets 

Target 

Facility Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 Percentage 

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

95 528 Buffalo 38 39 97 

528GK Lockport 45 50 90 

528GR Olean 45 45 100 

Lipid Profile 

Measure Meets 

Target 

Facility Qtr 1 

Numerator 

Qtr 1 

Denominator 

 Qtr 1 

Percentage 

DM - 

Renal 

Testing 

93 National 4,976 5,263 95 

93 528 Buffalo 37 39 95 

528GK Lockport 46 50 92 

528GR Olean 45 45 100 

Renal Testing, FY 2009

Measure Meets 

Target 

Facility Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 

Percentage 

Patient Screen 

with PC-PTSD 

90 National 4,751 4,987 95 

90 528 Buffalo 6 7 86 

528GK Lockport 8 8 100 

528GR Olean 4 4 100 

PTSD Screening, FY 2009 

VA Office of Inspector General 42 
CBOC Reviews: Lockport and Olean, Monaca and Washington, Berwick and Sayre, and Somerset

Appendix J 

Quality of Care Measures 

VA Pittsburgh HCS – Monaca and Washington 

Measure Facility 

Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 Percentage 

Hyperlipidemia 

Screen 

National 13,148 13,587 97 

646 Pittsburgh HCS 103 106 97 

 646GC Monaca 49 49 100 

 646GD Washington 49 50 98 

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 

646 Pittsburgh HCS 42 43 98 

646GC Monaca 44 44 100 

646GD Washington 44 45 98 

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 

646 Pittsburgh HCS 41 43 95 

646GC Monaca 44 44 100 

646GD Washington 44 45 98 

Foot Pedal Pulses, FY 2009 

Sensory Exam 

DM - Outpatient - Foot 

sensory exam using 

monofilament 

National 5,266 5,951 88 

646 Pittsburgh HCS 40 42 95 

646GC Monaca 44 44 100 

646GD Washington 44 45 98 

Foot Sensory, FY 2009

VA Office of Inspector General 43 
CBOC Reviews: Lockport and Olean, Monaca and Washington, Berwick and Sayre, and Somerset

Measure Meets 

Target 

Facility Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 

Percentage 

DM – Retinal 

Eye Exam 

88 National 4,599 5,258 87 

88 646 Pittsburgh HCS 31 36 86 

646GC Monaca 40 44 91 

646GD Washington 38 45 84 

Retinal Exam, FY 2009 

Measure Meets 

Target

 

Facility Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 

Percentage 

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

95 646 Pittsburgh HCS 25 25 100 

646GC Monaca 44 44 100 

646GD Washington 44 45 98 

Lipid Profile 

Measure Meets 

Target 

Facility Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 

Percentage 

DM - 

Renal 

Testing 

93 National 4,976 5,263 95 

93 646 Pittsburgh HCS 35 36 97 

646GC Monaca 44 44 100 

646GD Washington 45 45 100 

Renal Testing, FY 2009 

Measure Meets 

Target

 

Facility Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 

Percentage 

Patient Screen 

with PC-PTSD 

90 National 4,751 4,987 95 

90 646 Pittsburgh HCS 64 66 97 

646GC Monaca 29 29 100 

646GD Washington 16 20 80 

PTSD Screening, FY 2009 

VA Office of Inspector General 44 
CBOC Reviews: Lockport and Olean, Monaca and Washington, Berwick and Sayre, and Somerset

Appendix K 

Quality of Care Measures 

Wilkes-Barre VAMC – Berwick and Sayre 

Measure Facility 

Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 Percentage 

Hyperlipidemia 

Screen 

National 13,148 13,587 97 

693 Wilkes-Barre 100 105 95 

 693GF Berwick 8 9 89 

 693GA Sayre 9 9 100 

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 

693 Wilkes-Barre 46 46 100 

693GF Berwick 46 50 92 

693GA Sayre 50 50 100 

DM Foot Inspection, FY 2009 

 Measure Facility Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 Percentage 

DM - Outpatient Foot 

pedal pulses 

National 5,395 5,971 90 

693 Wilkes-Barre 45 46 98 

693GF Berwick 44 50 88 

693GA Sayre 49 50 98 

Foot Pedal Pulses, FY 2009 

Sensory Exam 

DM - Outpatient - 

Foot Sensory Exam 

Using Monofilament 

National 5,266 5,951 88 

693 Wilkes-Barre 41 46 89 

693GF Berwick 46 50 92 

693GA Sayre 49 50 98 

Foot Sensory, FY 2009 

VA Office of Inspector General 45 
CBOC Reviews: Lockport and Olean, Monaca and Washington, Berwick and Sayre, and Somerset 

Measure Meets 

Target 

Facility Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 

Percentage 

DM – 

Retinal 

Eye Exam 

88 National 4,599 5,258 87 

88 693 Wilkes-Barre 31 38 82 

693GF Berwick 41 50 82 

693GA Sayre 43 50 86 

Retinal Exam, FY 2009 

Measure Meets 

Target 

Facility Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 

Percentage 

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

95 693 Wilkes-Barre 38 38 100 

693GF Berwick 39 50 78 

693GA Sayre 50 50 100 

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 

93 693 Wilkes-Barre 37 38 97 

693GF Berwick 47 50 94 

693GA Sayre 48 49 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 

90 693 Wilkes-Barre 25 26 96 

693GF Berwick 12 12 100 

693GA Sayre 8 9 89 

PTSD Screening, FY 2009 

VA Office of Inspector General 46 
CBOC Reviews: Lockport and Olean, Monaca and Washington, Berwick and Sayre, and Somerset, KY 

Appendix L 

VA Office of Inspector General 47 

Quality of Care Measures 

Lexington VAMC – Somerset 

Measure Facility 

Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 Percentage 

Hyperlipidemia 

Screen 

National 13,148 13,587 97 

596 Lexington 102 104 98 

 596GA Somerset 50 50 100 

Hyperlipidemia Screening, FY 2009 

Measure Facility Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 

Percentage 

DM – Outpatient Foot 

Inspection 

National 5,523 5,971 92 

596 Lexington 46 46 100 

596GA Somerset 42 42 100 

DM Foot Inspection, FY 2009 

 Measure Facility Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 Percentage 

DM - Outpatient Foot 

pedal pulses 

National 5,395 5,971 90 

596 Lexington 46 46 100 

596GA Somerset 42 42 100 

Foot Pedal Pulses, FY 2009 

Sensory Exam 

DM - Outpatient - 

Foot Sensory Exam 

Using Monofilament 

National 5,266 5,951 88 

596 Lexington 46 46 100 

596GA Somerset 42 42 100 

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 

88 596 Lexington 31 38 82 

596GA Somerset 39 42 93 

Retinal Exam, FY 2009 
CBOC Reviews: Lockport and Olean, Monaca and Washington, Berwick and Sayre, and Somerset 

VA Office of Inspector General 48 

Measure Meets 

Target 

Facility Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 

Percentage 

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

95 596 Lexington 35 38 92 

596GA Somerset 40 42 95 

Lipid Profile 

Measure Meets 

Target 

Facility Qtr 1 

Numerator 

Qtr 1 

Denominator 

 Qtr 1 

Percentage 

DM - 

Renal 

Testing 

93 National 4,976 5,263 95 

93 596 Lexington 37 38 97 

596GA Somerset 42 42 100 

Renal Testing, FY 2009 

Measure Meets 

Target 

Facility Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 Percentage 

Patient Screen 

with PC-PTSD 

90 National 4,751 4,987 95 

90 596 Lexington 5 5 100 

596GA Somerset 19 21 90 

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 

60 596 Lexington * * * 

596GA Somerset 1 1 100 

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

 Null values are represented by *, indicating no eligible cases
CBOC Reviews: Lockport and Olean, Monaca and Washington, Berwick and Sayre, and Somerset

Appendix M 

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 

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 49 
CBOC Reviews: Lockport and Olean, Monaca and Washington, Berwick and Sayre, and Somerset

Appendix N 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, Veterans Integrated Service Network (10N2) 

Director, Veterans Integrated Service Network (10N4) 

Director, Veterans Integrated Service Network (10N9) 

Director, VA Western New York HCS (528/00) 

Director, VA Pittsburgh HCS (646/00) 

Director, Wilkes-Barre VAMC (693/00) 

Director, Lexington VAMC (596/00) 

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: Jim Bunning, Robert P. Casey, Jr., Kirsten E. Gillibrand, Mitch McConnell, 

Charles E. Schumer, Arlen Specter 

U.S. House of Representatives: Jason Altmire, Christopher P. Carney, Charles W. Dent, 

Paul E. Kanjorski, Christopher J. Lee, Eric J.J. Massa, Tim Murphy, Harold Rogers 

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

VA Office of Inspector General 50