Department of Veterans Affairs 

Office of Inspector General 

Healthcare Inspection 

Community Based Outpatient 

Clinic Reviews 

Benton Harbor and Grand Rapids, MI 

Terre Haute and Bloomington, IN 

Yale and Pontiac, MI 

Report No. 09-01446-199 August 20, 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: Benton Harbor & Grand Rapids, MI; Terre Haute & Bloomington, IN; Yale & Pontiac, MI 

Contents 

Page 

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

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

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

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

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

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

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

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

A. VISN 11, Battle Creek VAMC – Benton Harbor and Grand Rapids ...................... 6 

B. VISN 11, Indianapolis VAMC – Terre Haute and Bloomington........................... 11 

C. VISN 11, Detroit VAMC – Yale and Pontiac........................................................ 19 

Appendixes 

A. VISN 11 Director Comments................................................................................. 26
 

B. Battle Creek VAMC Director Comments .............................................................. 27 

C. Indianapolis VAMC Director Comments .............................................................. 30 

D. Detroit VAMC Director Comments....................................................................... 34 

E. CBOC Characteristics............................................................................................. 38 

F. Quality of Care Measures – Benton Harbor and Grand Rapids ............................. 40 

G. Quality of Care Measures – Terre Haute and Bloomington .................................. 42 

H. Quality of Care Measures – Yale and Pontiac ....................................................... 44 

I. OIG Contact and Staff Acknowledgments .............................................................. 46
 

J. Report Distribution.................................................................................................. 47
 

VA Office of Inspector General 
CBOC Reviews: Benton Harbor & Grand Rapids, MI; Terre Haute & Bloomington, IN; Yale & Pontiac, MI 

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 Office of Inspector General (OIG), Office of Healthcare Inspections conducted a 

review of six CBOCs during the week of May 18–22, 2009. The CBOCs reviewed were 

Benton Harbor and Grand Rapids, MI; Terre Haute and Bloomington, IN; and Yale and 

Pontiac, MI. The parent facilities of these CBOCs are Battle Creek VAMC, Richard L. 

Roudebush (Indianapolis) VAMC, and John D. Dingell (Detroit) 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. The CBOCs and parent 

facilities are all part of Veterans Integrated Service Network (VISN) 11. 

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 Director, 

VISN 11, in conjunction with the respective facility manager, should take appropriate 

actions on the following recommendations: 

•	 Accomplish providers’ background checks in accordance with VHA policy. 

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

•	 Implement appropriate measures as described in the security risk assessment. 

•	 Maintain protected patient information in a secure fashion and monitor 

appropriate shredding practices. 

•	 Require that clinicians order and provide emergency medications according to the 

terms of their contracts, appropriately document medications ordered for shortterm use in computerized patient record system (CPRS), and monitor 

documentation of the appropriate process. 

•	 Assess the need for an emergency box and maintain its contents appropriately if 

one is deemed necessary. 

•	 Ensure all medications and instruments accessible to patients are secured when 

unattended. 

•	 Maintain an emergency management policy relevant to the specific needs and 

resources of each CBOC. 

VA Office of Inspector General i 
CBOC Reviews: Benton Harbor & Grand Rapids, MI; Terre Haute & Bloomington, IN; Yale & Pontiac, MI 

•	 Provide proper CBOC access to disabled patients. 

•	 Grant privileges that are consistent with providers’ practices and ensure that the 

Professional Standards Board minutes appropriately reflect documents reviewed 

and actions taken. 

•	 Ensure monitoring of prescriptive authority is consistently accomplished, reports 

are forwarded to the credentialing office, and results are used during the 

reprivileging processes. 

•	 Include provider-specific performance measure data in the reprivileging process as 

required by VA policy. 

•	 Require that all licensed independent providers are privileged for procedures 

provided at CBOCs as required by VHA. 

•	 Recover the overcharges for the duplicate billings from the contractor. 

•	 Include a provision for contractor billing on a monthly basis to reduce the charges 

to the VA when contracts are terminated. 

•	 Provide a provision in contracts for disenrollment of veterans who have not 

received services at the CBOC within the prior 12 months. 

Comments 

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

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

pages 26–37, 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 

VA Office of Inspector General ii 
 

 

CBOC Reviews: Benton Harbor & Grand Rapids, MI; Terre Haute & Bloomington, IN; Yale & Pontiac, MI 

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, the 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. 

VA Office of Inspector General 1 
 

CBOC Reviews: Benton Harbor & Grand Rapids, MI; Terre Haute & Bloomington, IN; Yale & Pontiac, MI 

•	 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. 

VA Office of Inspector General 2 
 

 

 

CBOC Reviews: Benton Harbor & Grand Rapids, MI; Terre Haute & Bloomington, IN; Yale & Pontiac, MI 

Part II. CBOC Characteristics 

Veterans Integrated Service Network (VISN) 11 has 8 VHA hospitals and 21 CBOCs. 

As part of our review, we inspected 6 CBOCs (1 VA leased and 5 contracted).3 There 

were 2 CBOCs each from 3 VAMCs. The CBOCs reviewed were Benton Harbor and 

Grand Rapids, MI; Terre Haute and Bloomington, IN; and Yale and Pontiac, MI. The 

parent facilities of these CBOCs are Battle Creek VAMC, Richard L. Roudebush 

(Indianapolis) VAMC, and John D. Dingell (Detroit) VAMC, respectively. 

We formulated a list of CBOC characteristics and developed a questionnaire 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 VA-staffed CBOCs was 

8,807 (range 2,494 to 15,121), and the contract CBOCs averaged 8,611 (range 3,004 to 

4,154). The overall average of unique patients was 5,343 (range 2,494 to 15,121). 

Figure 1 shows characteristics of the six 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 

11 Benton Harbor, 

MI 

Battle Creek, 

MI 

VA Staffed Rural 3.00 2,494 9,145 

11 Grand Rapids, 

MI 

Battle Creek, 

MI 

VA Staffed Urban 12.35 15,121 94,939 

11 Terre Haute, IN Indianapolis, 

IN 

Contract Rural 4.00 4,154 8,309 

11 Bloomington, 

IN 

Indianapolis, 

IN 

Contract Rural 5.00 4,272 7,911 

11 Yale, MI Detroit, MI Contract Rural 2.2 3,015 7,634 

11 Pontiac, MI Detroit, MI Contract Urban 4.05 3,004 5,987 

Figure 1 - CBOC Characteristics, FY 2008 

Three of the six CBOCs provide Specialty Care services onsite (Grand Rapids, Terre 

Haute, Bloomington), while the other three CBOCs refer patients to the parent facility. 

Benton Harbor also refers patients to a contract or fee basis facility and VA hospitals in 

Ann Arbor and Detroit. The specialty services conducted at the Grand Rapids CBOC 

included dermatology, gastrointestinal, rheumatology, urology, endocrinology, 

optometry, infectious disease, women’s wellness, podiatry, dental, ultrasound, speech 

pathology, audiology, wound program, and occupational and physical therapy. The 

specialty services offered at the Terre Haute and Bloomington CBOCs include nutrition 

and wheelchair clinics. 

3

 Benton Harbor CBOC changed from a contract to a VA staffed facility in November 2008. 

VA Office of Inspector General 3 
 

 

CBOC Reviews: Benton Harbor & Grand Rapids, MI; Terre Haute & Bloomington, IN; Yale & Pontiac, MI 

While four of the six CBOCs have laboratory services onsite, only two of the four (Grand 

Rapids and Benton Harbor) were able to provide basic blood analysis and only one 

CBOC (Grand Rapids) provided urine analysis onsite. All six CBOCs provide 

electrocardiograms (EKGs). Two CBOCs have an onsite pharmacy (Grand Rapids and 

Yale), and five CBOCs provided radiological services. Veterans have access to social 

services at two CBOCs. 

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

CBOCs to include psychologist, licensed clinical social workers, nurse practitioners, 

social services specialists, and psychiatrists. Tele-mental health is available at three 

CBOCs (Benton Harbor, Yale, and Pontiac). Four CBOCs reported that MH services are 

provided 5 days a week (Benton Harbor, Grand Rapids, Terre Haute, and Bloomington). 

Yale provides MH 2 days per week and Pontiac 3 days per week. Additional CBOC 

characteristics are listed in Appendix E. 

VA Office of Inspector General 4 
CBOC Reviews: Benton Harbor & Grand Rapids, MI; Terre Haute & Bloomington, IN; Yale & Pontiac, MI 

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 was discussed in detail in the Informational Report for 

the Community Based Outpatient Clinic 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 issued November 14, 2008. 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 target goal, we interviewed the senior managers to assess 

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

We evaluated whether the five CBOC contracts provided guidelines that the contractor 

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

number of enrollees or visits reported was supported by collaborating documentation. 

VA Office of Inspector General 5 
 

CBOC Reviews: Benton Harbor & Grand Rapids, MI; Terre Haute & Bloomington, IN; Yale & Pontiac, MI 

Part IV. Results and Recommendations 

A. VISN 11, Battle Creek VAMC – Benton Harbor and Grand Rapids 

Quality of Care Measures 

The Benton Harbor CBOC equaled or exceeded the parent facility’s quality measure 

scores for hyperlipidemia screening, diabetes mellitus (DM) foot inspections, pedal 

pulses, and foot sensory exams using monofilament. The Benton Harbor CBOC had 

slightly lower scores than the parent facility for the retinal eye exams. Both the Grand 

Rapids and Benton Harbor CBOCs equaled the parent facility’s quality measure scores 

for renal testing. Grand Rapids CBOC had slightly lower scores than the parent facility 

in the following quality measures: DM foot inspections, pedal pulses, foot sensory exams 

using monofilament, retinal eye exams, and lipid profiles. (See Appendix F.) 

Credentialing and Privileging 

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

the Grand Rapids CBOC and five providers and three nurses at the Benton Harbor 

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

nurses’ license and education requirements were verified and documented. Although the 

C&P and personnel folders were in compliance, we did find that the background checks 

process at both CBOCs needed improvement: 

Background Checks 

According to VHA policy,4

 all Federal appointments are subject to background checks. 

Background investigations must be initiated within 14 calendar days of an individual’s 

appointment to a position. One provider at the Benton Harbor CBOC did not have a 

background check on file. This provider transferred from another VA facility on 

March 1, 2009. At the time of our inspection, Human Resources (HR) had not received 

the provider’s personnel file from the transferring facility. One nurse at the Grand 

Rapids CBOC did not have a background check on file. HR initiated the background 

check within 14 days; however, the Office of Personnel Management (OPM) requested 

additional information over 1 year ago. At the time of our inspection, HR had not 

submitted the additional information to OPM. 

Recommendation 1. We recommended that the VISN 11 Director ensure that the Battle 

Creek VA Medical Center Director requires all background checks be accomplished in 

accordance to VHA policy. 

4

 VHA Handbook 0710, Personnel Suitability and Security Program, September 10, 2004. 

VA Office of Inspector General 6 
 

CBOC Reviews: Benton Harbor & Grand Rapids, MI; Terre Haute & Bloomington, IN; Yale & Pontiac, MI 

The VISN and Medical Center Directors concurred with our finding and 

recommendation. A screening checklist will be utilized for every applicant, and any 

incomplete investigations will be tracked by the Human Resource Quality Management 

Specialist on a weekly basis. 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 internal EOC was clean and well maintained at 

both sites; however, we found that the following areas needed improvement: 

Auditory Privacy 

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

Harbor CBOC. VHA policy5

 requires auditory privacy when staff discuss sensitive 

patient issues. 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 the check-in process, at a minimum, patients are asked their names, last four of 

the social security number (SSN), and the reason(s) for the visit. 

Panic Alarms 

The Benton Harbor CBOC provides MH services but did not have a panic alarm system 

for staff to activate in the event of threats of violence. According to the local policy, staff 

are to dial 911 to obtain assistance. The CBOC managers were aware of the need for a 

panic alarm system and had planned to purchase panic buttons for their staff. 

Recommendation 2. We recommended that the VISN 11 Director ensure that the Battle 

Creek VA Medical Center Director requires auditory privacy be maintained during the 

check-in process. 

The VISN and Medical Center Directors concurred with our finding and 

recommendation. The waiting room seating has been rearranged and seats are no longer 

located next to the check-in area, and the clinic has revised the check-in process to 

decrease the amount of patient information that is verbally shared. The improvement 

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

completed. 

5 VHA Handbook 1605.1, Privacy and Release of Information, May 17, 2006. 

VA Office of Inspector General 7 
 

 

 

 

 

 

 

CBOC Reviews: Benton Harbor & Grand Rapids, MI; Terre Haute & Bloomington, IN; Yale & Pontiac, MI 

Recommendation 3. We recommended that the VISN 11 Director ensure that the Battle 

Creek VA Medical Center Director implements a panic alarm system at the Benton 

Harbor CBOC. 

The VISN and Medical Center Directors concurred with our finding and 

recommendation. Personal alarm devices will be obtained for all staff members at the 

Benton Harbor CBOC. The improvement plans are acceptable, and we will follow up on 

the planned actions until they are completed. 

Emergency Management 

Both CBOCs had a local policy for handling medical and MH emergencies. Staff 

members interviewed at both sites described how they would handle both clinical and 

MH emergencies, and staff responses were in compliance with local policy. All clinical 

staff members at both CBOCs were certified in Basic Cardiac Life Support (BCLS). 

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) 

515 Battle Creek Mean 

Score 

85.8 83.3 69.3 78.3 78.5 

N= 89 74 71 2,126 54,400 

515BY Grand 

Rapids 

88.1 85.2 79.5 

N= 87 83 76 

515GC Benton 

Harbor 

67.6 64.3 69.9 

N= 54 68 75 

Figure 2. Outpatient Overall Quality 

The Benton Harbor scores were below the VHA target score of 77, while the Grand 

Rapids scores were above the target score of 77 for all quarters for the “overall quality” 

indicator. SHEP results are discussed in monthly staff meetings and the Quality 

Assessment and Improvement Committee meetings at the Benton Harbor CBOC. In 

April 2009, staff developed an action plan to interview 15 patients daily to assess their 

healthcare experience during that visit. 

VA Office of Inspector General 8 
 

 

 

 

 

 

 

CBOC Reviews: Benton Harbor & Grand Rapids, MI; Terre Haute & Bloomington, IN; Yale & Pontiac, MI 

Trip 

Pati

2008 SH

YTD 

ent Percep

EP Perfor

Pak Repor

Through S

tions of 

mance 

t - STA5 

M

eptember 

Care 

Level 

easures 

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) 

515 Battle Creek Mean 

Score 

88 92 74.8 79.3 77.3 

N= 87 73 74 2,210 55,407 

515BY 88.1 85.2 79.5 

Grand 

Rapids 

N= 87 83 76 

515GC 

Benton 81.8 79.2 78.8 

Harbor 

N= 59 68 73 

Figure 3. Provider Wait Times 

Both CBOCs exceeded the parent facility’s 2nd Qtr score but scored below the parent 

facility during the 3rd Qtr. Both CBOCs met VHA’s target goal of 77 percent for 

“provider wait times.” 

CBOC Contract 

The contract for the Benton Harbor CBOC is administered through the Battle Creek 

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

continuity of care for all eligible veterans in VISN 11. Contracted services with CR 

Associates, Inc. (CRA) began on November 1, 2003, with option years extending through 

October 31, 2008. Effective November 1, 2008, the VAMC terminated its contract with 

CRA and now operates a facility with VA employees. The contract terms state that the 

CBOC will operate this clinic with a clinic director, physician licensed in Michigan, and 

other primary care providers including physicians’ assistants and nurse practitioners. The 

contractor was compensated by the number of enrollees at an annual capitated rate of 

$333.00 per enrollee. The CBOC had 2,494 unique primary medical care enrollees with 

9,145 visits as reported on the VA Site Tracking (VAST) report for the period October 1, 

2007, through September 30, 2008. 

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

invoices submitted, and supporting information and performed inquiries of key 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 

VA Office of Inspector General 9 
 

CBOC Reviews: Benton Harbor & Grand Rapids, MI; Terre Haute & Bloomington, IN; Yale & Pontiac, MI 

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

Technical Representative (COTR); and duplicate, missing or incomplete SSNs on the 

invoices. 

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

noted the following: 

A.	 The contractor over-billed the VAMC the annual capitated rate for three primary 

care enrollees during the period December 2007 through October 2008. This 

duplicate billing resulted in an overpayment of $999.00 for Primary Care Services. 

The Statement of Work, Section I–Primary Care Services, specifically precludes 

the contractor from billing for the same enrollee twice within any given 12-month 

period. 

B.	 The contract contained a provision regarding the payment of an annual capitated 

rate of $333.00 (Primary Care) for new enrollees which was disadvantageous to 

the VAMC when the contract was terminated in November 2008. In October 

2008, the contractor billed the VAMC $68,265 for 205 primary care enrollees 

while providing one month of service for the newly enrolled veterans. 

C.	 The billings for prior months reflect a similar pattern; i.e., September enrollee 

billings totaled $63,270 (Primary Care) for providing two months of health care 

for the newly enrolled veterans. 

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

Creek VA Medical Center Director recovers the overcharges for the duplicate billings 

from the vendor. Additionally, any future contracts should contain a provision for 

contractor billing on a monthly basis to reduce the charges to the VA when contracts are 

terminated. 

The VISN and Medical Center Directors concurred with our finding and 

recommendation. The VAMC has issued a bill of collection to the vendor for 

overcharges. The contract CBOC has converted to a VA-staffed facility; therefore, no 

contract provision needs to be developed. The improvement plans are acceptable, and we 

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

VA Office of Inspector General 10 
 

 

 

CBOC Reviews: Benton Harbor & Grand Rapids, MI; Terre Haute & Bloomington, IN; Yale & Pontiac, MI 

B. VISN 11, Indianapolis VAMC – Terre Haute and Bloomington 

Quality of Care Measures 

The Terre Haute CBOC quality measure scores were slightly lower than the parent 

facility for the following indicators: DM foot inspection and DM foot pedal pulse screen. 

The Bloomington CBOC did not meet the target goal for PTSD screening, but the sample 

size was very small. (See Appendix G.) 

Credentialing and Privileging 

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

the Bloomington CBOC and reviewed five providers and two nurses at Terre Haute. All 

providers possess a full, active, current, and unrestricted license. However, we identified 

the following areas which needed improvement: 

Privileging 

Professional Standards Review Board Minutes 

The Professional Standards Board (PSB) had granted providers clinical privileges for 

procedures that had not been performed within the past reprivileging cycle. For example, 

two primary care physicians were granted privileges to perform suturing although 

suturing was not a procedure performed at the CBOCs. 

The minutes of the PSB did not consistently reflect actions taken by the board. In two 

instances, the minutes did not include discussion of documents or evidence reviewed 

prior to forwarding recommendations for approval of privileges or Scopes of Practice.6 

In one instance, the Chief of Staff recommended that a provider be monitored for three 

months, but there was no further discussion in the PSB minutes about the monitoring or 

resolution of the monitoring. According to the staff we interviewed, the monitoring did 

not take place. 

Monitoring of Advanced Practice Nurses 

We found inconsistencies in the monitoring of the Advanced Practice Nurses’ 

prescriptive authority. We examined the quarterly reports for 2007, 2008, and 2009 and 

found that one of the nurse practitioners had missing data for one quarter in 2007. Also, 

three of five nurse practitioners’ quarterly monitoring reports were not forwarded to the 

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 health care providers. The scope of practice is specific to the individual 

and the facility involved. 

VA Office of Inspector General 11 
CBOC Reviews: Benton Harbor & Grand Rapids, MI; Terre Haute & Bloomington, IN; Yale & Pontiac, MI 

credentialing office as required. Staff told us that reports were not always available for 

the PSB to review prior to granting privileges. 

The Indiana Board of Nursing and local Scope of Practice require that the collaborating 

physician conduct a weekly review of a minimum of 5 percent of patient documentation 

encounters. The charts should be reviewed for clinical pertinence and the weekly reports 

forwarded to the credentialing office for use during the re-privileging evaluation. This 

was not consistently documented in the PSB minutes. 

Recommendation 5. We recommended that the VISN 11 Director ensure that the 

Indianapolis VA Medical Center Director requires that clinical managers grant privileges 

that are consistent with providers’ practices and ensure that the minutes of the PSB 

appropriately reflect documents reviewed and actions taken. 

The VISN and Medical Center Directors concurred with our finding and 

recommendation. A revised clinical privilege form for the CBOC will be presented at the 

next Executive Committee of the Medical Staff for approval. Separate PSB meeting 

minutes will be developed to document the actions for the CBOC Advanced Practice 

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

actions until they are completed. 

Recommendation 6. We recommended that the VISN 11 Director ensure that the 

Indianapolis VA Medical Center Director requires that the monitoring of prescriptive 

authority is consistently accomplished, reports are forwarded to the credentialing office, 

and results are used during the re-privileging processes. 

The VISN and Medical Center Directors concurred with our finding and 

recommendation. A process has been instituted to contact any Nurse Practitioner who is 

delinquent in submitting quarterly medical record review reports. 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

VHA regulations require that health care facilities provide clean, safe environments in all 

patient care areas and establish comprehensive EOC programs that fully meet all VHA, 

OSHA, and Joint Commission standards. To evaluate the EOC, we inspected patient care 

areas for cleanliness, safety, infection control, and general maintenance. The clinics met 

most standards, and the environments were generally clean and safe. However, we found 

the following areas that needed improvement: 

VA Office of Inspector General 12 
CBOC Reviews: Benton Harbor & Grand Rapids, MI; Terre Haute & Bloomington, IN; Yale & Pontiac, MI 

Personally Identifiable Information 

Control of the environment includes control of confidential patient personally identifiable 

(PII) information according to Health Insurance Portability and Accountability Act

(HIPAA) regulations. In the Bloomington clinic, we found a folder with patient 

information on a provider’s desk in an office that was unlocked and unattended. In the 

same office, we also found pages from a patient’s medical record in the wastebasket. The 

pages had been torn into several pieces, but the information on the torn pieces was still 

readable and was not in a bin designated for shredding. In both clinics, we found boxes 

of medical records with protected patient information stored in closets. The closets were 

locked; but, at one of the clinics, the closet with the PII was also in the biohazard storage 

closet and regularly accessed by cleaning crews. 

Patient Safety Medication Management 

Both the Bloomington and Terre Haute clinics are contract clinics. According to the 

contracts, if a patient requires a medication immediately, “the CBOC provider shall issue 

a prescription for a 10-day supply (or less) to the patient from a pre-approved list of 

emergency medications, to be filled by a local pharmacy at no expense to the VAMC or 

the veteran.” We found that a list of pre-approved medications did not exist nor did the 

clinics routinely use local pharmacies to dispense emergency medications. The clinics 

had a stock of medications and would provide the veteran with the ordered medication 

from their in-clinic stock for short-term management of “immediate” medical conditions. 

We reviewed the computerized patient record system (CPRS) progress notes of two 

veterans who received medications in this manner. In one record, the medication did not 

appear on the medication list as having been ordered and filled at the clinic. The other 

record did not include a note by the provider who ordered the medication. This record 

included a note by the nurse and a “receipt acknowledged” of the nurse’s note by the 

provider. 

Panic Alarms 

Both CBOCs provide MH services, but neither clinic had panic alarms for either the 

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

need for assistance, they would call out for help. 

Accessible Approach/Entrance 

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

assistive devices to independently maneuver to the clinic door. However, there was no 

doorbell or handicap assist button to help the patient open the front door. The staff 

indicated that patients who required assistance opening the door were usually escorted to 

their appointments, and the escorts would open the door so the patient could gain entry. 

VA Office of Inspector General 13 
CBOC Reviews: Benton Harbor & Grand Rapids, MI; Terre Haute & Bloomington, IN; Yale & Pontiac, MI 

Recommendation 7. We recommended that the VISN 11 Director ensure that the 

Indianapolis VA Medical Center Director requires clinical managers maintain protected 

patient information in a secure fashion and monitor appropriate shredding practices. 

The VISN and Medical Center Directors concurred with our finding and 

recommendation. CBOC staff will receive training on maintaining protected patient 

information, and EOC rounds will be conducted to include inspection for appropriate 

storage and disposal of the information. The improvement plans are acceptable, and we 

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

Recommendation 8. We recommended that the VISN 11 Director ensure that the 

Indianapolis VA Medical Center Director requires that clinicians order and provide 

emergency medications according to the terms of their contracts, appropriately document 

medications ordered for short-term use in CPRS, and monitor documentation of the 

appropriate process. 

The VISN and Medical Center Directors concurred with our finding and 

recommendation. The facility has discontinued the dispensing of outpatient medications, 

and short-term prescriptions will be written to be filled at an outside pharmacy as per the 

contract. 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 11 Director ensure that the 

Indianapolis VA Medical Center Director conduct a security risk assessment and evaluate 

the assessment to determine appropriate measures to take at both CBOCs. 

The VISN and Medical Center Directors concurred with our findings and 

recommendation. VA Police Service will conduct a security risk assessment, and the 

medical center will evaluate the assessment to determine appropriate measures. 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 11 Director ensure that the 

Indianapolis VA Medical Center Director requires that patients in wheelchairs or with 

other assistive devices have proper access to the Terre Haute and Bloomington CBOCs. 

The VISN and Medical Center Directors concurred with our findings and 

recommendation. Door bells will be installed at the entrances for accessibility by patients 

in wheelchairs or with other assistive devices. 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 defining how medical emergencies are handled, including MH emergencies. 

VA Office of Inspector General 14 
CBOC Reviews: Benton Harbor & Grand Rapids, MI; Terre Haute & Bloomington, IN; Yale & Pontiac, MI 

The Terre Haute and Bloomington CBOCs had policies that outlined management of 

medical and MH emergencies. Staff members were able to articulate the principles 

underlying the policies. However, we found the following areas needed improvement. 

Medications in Emergency Boxes 

Despite the fact that the Terre Haute and Bloomington CBOCs are 911 facilities, 

emergency boxes were present in both CBOCs. Per staff interview, during an evacuation 

for fire or weather, the boxes were retrieved and the contents used for emergencies 

arising during an evacuation. A list of the contents was not attached to the outside of the 

box although a list was provided upon request. Two of the medications in the 

Bloomington CBOC’s emergency box were expired. 

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

Indianapolis Medical VA Director requires clinic managers to assess the need for an 

emergency box and to maintain its contents appropriately if one is deemed necessary. 

The VISN and Medical Center Directors concurred with our finding and 

recommendation. The emergency box will be maintained, and medication expiration 

dates and inventory will be conducted according to Joint Commission standards. 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) 

583 Indianapolis Mean 

Score 

66 66.1 74.1 78.3 78.5 

N= 78 61 61 2,126 54,400 

583GA Terre Haute 90.4 86.4 82.3 

. N= 66 65 75 

583GB Bloomington 88 69.1 74.6 

N= 78 66 72 

Figure 4. Outpatient Overall Quality 

VA Office of Inspector General 15 
CBOC Reviews: Benton Harbor & Grand Rapids, MI; Terre Haute & Bloomington, IN; Yale & Pontiac, MI 

The Bloomington CBOC scored below the target of 77 percent for Qtrs 2 and 3 for 

“overall quality” but improved its performance considerably in the last quarter. Both 

CBOCs equaled or outperformed the parent facility despite the two low quarters. 

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, 

Qtr4 

National 

FY08, 

Qtr 4 

(Q6) - 

(percent Less 

than/equal to 

20 minutes) 

583 Indianapolis Mean 

Score 

69.3 73.4 83.2 79.3 77.3 

 N= 75 59 63 2,210 55,407 

583GA Terre Haute 96.9 90.7 94.1 

 N= 69 67 77 

583GB Bloomington 91 90.7 87.9 

N= 83 67 75 

Figure 5. Provider Wait Times 

The CBOCs scored above the parent facility and met the target goal of 77 for “provider 

wait times” for all quarters. 

CBOC Contract 

The contracts for the Terre Haute and Bloomington CBOCs are administered through the 

Indianapolis VAMC for delivery and management of primary and preventative medical 

care and continuity of care for all eligible veterans in VISN 11. Both of the CBOCs have 

contracted services with Ambulatory Care Solutions, LLC. 

Terre Haute CBOC 

Contracted services with Ambulatory Care Solutions, LLC began on February 1, 2006, 

with option years extending through January 31, 2009. Their current contract was 

administered under a 6-month extension for the period February 1, 2009, through July 31, 

2009. The contract terms state that the CBOC will operate this clinic with a clinic 

director, physician licensed in Indiana, and other primary care providers including 

physicians’ assistants and nurse practitioners. The contractor is compensated by the 

number of enrollees at a current capitated rate of $36.75 per month, per enrollee. The 

contractor is limited to a total of 4,400 assigned veterans at any given time. The CBOC 

had 4,154 unique enrollees with 8,309 visits as reported on the VAST report for the 

period October 1, 2007, through September 30, 2008. The contract contained 

performance incentives and penalties dependent upon contractor performance levels. The 

VA Office of Inspector General 16 
CBOC Reviews: Benton Harbor & Grand Rapids, MI; Terre Haute & Bloomington, IN; Yale & Pontiac, MI 

contractor’s performance did not meet the criteria for either incentives or penalties during 

the 1st Qtr, FY 2009. 

The contractor has the authority to enroll and verify eligibility of patients for VA benefits 

and care. Veterans were enrolled and tracked through the Primary Care Management 

Module (PCMM). For the period October 1 through December 31, 2008, the number of 

invoiced enrollees did not exceed the contractor limitation of 4,400 enrollees. 

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

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

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

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

December 31, 2008. 

Bloomington CBOC 

Contracted services with Ambulatory Care Solutions, LLC began on March 1, 2006, with 

options years extending through February 28, 2009. The current contract is administered 

under a 6-month extension for the period March 1 through August 31, 2009. The 

contract terms state that the CBOC will operate this clinic with a clinic director; 

physician licensed in Indiana, and other primary care providers including physicians’ 

assistants and nurse practitioners. The contractor is compensated by the number of 

enrollees at a current capitated rate of $37.35 per month, per enrollee. The contractor is 

limited to a total of 4,400 assigned veterans at any given time. The CBOC had 4,272 

unique enrollees with 7,911 visits as reported on the VAST report for the period October 

1, 2007, through September 30, 2008. The contract contained performance incentives 

and penalties dependent upon contractor performance levels. 

The contractor has the authority to enroll and verify eligibility of patients for VA benefits 

and care. Veterans were enrolled and tracked through the PCMM. For the period 

October 1 through December 31, 2008, the number of invoiced enrollees did not exceed 

the contractor limitation of 4,400 enrollees. 

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

invoices submitted, and supporting information and performed inquiries of key 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 

VA Office of Inspector General 17 
CBOC Reviews: Benton Harbor & Grand Rapids, MI; Terre Haute & Bloomington, IN; Yale & Pontiac, MI 

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. 

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

noted the following: 

The contractor billed the VAMC at a capitated rate of $37.75/month/enrollee instead of 

the contracted rate of $37.35/month/enrollee for the period June 2008 through April 

2009. This error in billing resulted in the VAMC disbursing $15,127 more than the 

contracted amount. 

Recommendation 12. We recommended that the VISN 11 Director ensure that the 

Indianapolis VA Medical Director recovers the overcharges from the vendor and that 

future invoices are verified for compliance with contract provisions. 

The VISN and Medical Center Directors concurred with our finding and 

recommendation. The overcharges have been brought to the attention of the contractor 

who has initiated repayment. The improvement plans are acceptable, and we will follow 

up on the planned actions until they are completed. 

VA Office of Inspector General 18 
CBOC Reviews: Benton Harbor & Grand Rapids, MI; Terre Haute & Bloomington, IN; Yale & Pontiac, MI 

C. VISN 11, Detroit VAMC – Yale and Pontiac 

Quality of Care Measures 

Overall both CBOCs equaled or exceeded their parent facility’s quality measure scores. 

However, upon comparison of quality of care measures between the parent facility and 

the CBOCs, we found that the VAMC and Pontiac CBOC did not meet the target scores 

in DM retinal exam and DM lipid screening. The Yale CBOC was below the quality of 

care measures in PTSD screening. (See Appendix H.) 

Credentialing and Privileging 

We reviewed the C&P files of five providers at each CBOC. The VAMC conducted 

credentialing of all licensed independent providers (LIPs). All providers possess a full, 

active, current, and unrestricted license. Additionally, the VAMC had a system in place 

to monitor the quality of care provided by LIPs to veterans and had a plan in place to 

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

expected performance. However, we identified the following areas that needed 

improvement: 

Privileging 

Although, we found the nurse practitioners and physician assistants’ Scopes of Practice 

were defined in each C&P file, there was no evidence that licensed physicians at either 

CBOC were privileged. According to VHA Handbook 1100.19, all health care 

professionals who are permitted by law and the facility to provide patient care services 

independently must be credentialed and privileged, and only privileges for procedures 

actually provided by the VA facility may be granted to a practitioner. 

Yale CBOC 

The Yale CBOC was fully contracted through the Port Huron Hospital. The contract 

provision did not require that providers be privileged through the parent VAMC; instead, 

the provision provided an option of membership to an accredited healthcare organization 

or adherence to VA policy. The language of the contract read, “The licensed independent 

practitioners providing care to veteran patients under the contract must be members of an 

OFFICIAL Accredited health care organization or satisfy the rules and regulations of the 

Department of Veterans Affairs, Veterans Health Administration for credentialing and 

privileging (VHA Handbook 1100.19).” 

Pontiac CBOC 

We found that the Pontiac CBOC was fully contracted through the Pontiac Osteopathic 

Hospital. The CBOC contract provision required that the contract physician be a boardcertified internist and must be credentialed and privileged by VAMC in accordance with 

VA Office of Inspector General 19 
CBOC Reviews: Benton Harbor & Grand Rapids, MI; Terre Haute & Bloomington, IN; Yale & Pontiac, MI 

Medical Center by-laws, rules, and regulations. Upon review of the C&P files and 

discussion with the C&P coordinators, we found that providers’ privileges were for the 

contracting hospital and not for the Pontiac CBOC. Privileges are setting specific; 

therefore, privileges must be facility specific and based on the procedures and types of 

services that are provided within the health care facility. 

Performance Improvement Activities 

We did not find provider-specific results of performance measure data were used during 

the reprivileging process of LIPs at the Pontiac and Yale CBOCs. The Primary Care 

Service Chief must document that the results of quality of care activities have been 

considered in recommending individual privileges. Upon completion of this assessment, 

the service chief makes a recommendation as to the practitioner's request for clinical 

privileges. VA policy requires that reprivileging must occur every 2 years and that 

provider-specific performance improvement data is used to determine if the provider is 

competent to perform the privileges he is seeking. Detroit VAMC did not start utilizing 

the provider-specific performance improvement data until October 2008. 

Recommendation 13. We recommended that the VISN 11 Director ensure that the 

Detroit VA Medical Center Director requires that all LIPs are privileged for procedures 

provided at CBOCs as required by VHA. 

The VISN and Medical Center Directors concurred with our findings and 

recommendation. The PSB has recommended approval of requested privileges and 

reviewed scope of practices for both CBOCs. 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 11 Director ensure that the 

Detroit VA Medical Center Director requires that provider-specific performance measure 

data is included in the reprivileging process for both CBOCs as required by VA policy. 

The VISN and Medical Center Directors concurred with our findings and 

recommendation. The medical center has developed a process to ensure that providerspecific performance measure data is used during the re-privileging process at both 

CBOCs. 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 

VHA regulations require that health care facilities provide clean, safe environments in all 

patient care areas and establish comprehensive EOC programs that fully meet all VHA, 

OSHA, and Joint Commission standards. To evaluate the EOC, we inspected patient care 

areas for cleanliness, safety, infection control, and general maintenance. The Pontiac 

VA Office of Inspector General 20 
CBOC Reviews: Benton Harbor & Grand Rapids, MI; Terre Haute & Bloomington, IN; Yale & Pontiac, MI 

CBOC met all standards, and the environment was generally clean and safe. The Yale 

CBOC met most standards, and the environment was generally clean and safe. However, 

we found the following areas at the Yale CBOC that needed improvement: 

Patient Safety and Infection Control 

During the Yale CBOC environmental tour, an injectable prescription medication and 

uncovered medical instruments were observed on a counter in an unattended, unlocked 

procedure room. CBOCs are expected to comply with all relevant VHA policies and 

procedures, including those related to patient safety. Unattended medications could pose 

a hazard to patients, and medical instruments must be kept covered and secured when 

unattended to avoid possible contamination. 

Recommendation 15. We recommended that the VISN 11 Director ensure that the 

Detroit VA Medical Center Director requires that all medications accessible to patients 

receiving care at CBOCs are secured when unattended. 

The VISN and Medical Center Directors concurred with our finding and 

recommendation. The facility took appropriate measures to ensure medications are 

stored when not in used and disposed of after use in the proper receptacle. Follow-up 

action is acceptable; therefore, no further action is required. 

Recommendation 16. We recommended that the VISN 11 Director ensure that the 

Detroit VA Medical Center Director requires that all instruments accessible to CBOC 

staff and patients receiving care at CBOCs are covered and secured when not in use or 

unattended. 

The VISN and Medical Center Directors concurred with our finding and 

recommendation. The facility took appropriate measures to ensure medical instruments 

are properly stored. Follow-up action is acceptable; therefore, no further action is 

required. 

Emergency Management 

To evaluate the Emergency Management Plan, we reviewed local medical (including 

MH) and environmental emergency policies. We also interviewed clinical and support 

staff. Both facilities had local environmental and MH emergency policies that were 

relevant to the specific needs and resources of each CBOC. Staff at each facility easily 

articulated responses that accurately reflected those local policies. However, we 

identified the following area that needed improvement: 

VA Office of Inspector General 21 
 

 

 

 

 

 

 

CBOC Reviews: Benton Harbor & Grand Rapids, MI; Terre Haute & Bloomington, IN; Yale & Pontiac, MI 

Medical Emergency Response 

Both CBOCs had an on-site automated external defibrillator (AED)7

 and medications to 

respond to a medical emergency. Staff at the Yale and Pontiac CBOCs indicated the 

response to a medical emergency would include summoning the local emergency 

response system (911) and administering emergency medications, along with utilizing the 

AED as necessary. These responses did not reflect the local medical emergency response 

policies, which did not include the use of emergency medications as a part of either 

facility’s medical emergency response plan. 

Recommendation 17. We recommended that the VISN 11 Director ensure that the 

Detroit VA Medical Center Director requires that each CBOC have an emergency 

management policy relevant to the specific needs and resources of each CBOC. 

The VISN and Medical Center Directors concurred with our findings and 

recommendation. Both CBOCs revised their emergency management policy to include 

the use of AED and administration of emergency medications. 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. We found significant 

difference between the SHEP scores for the CBOCs and the parent facility in the “overall 

quality” and “provider wait time” indicators. 

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) 

553 Detroit Mean 

Score 

65.7 60.5 77.2 78.3 78.5 

N= 87 66 68 2,126 54,400 

553GA Yale 91.3 83 86.8 

N= 83 72 71 

553GB Pontiac 94.6 81.4 94.9 

. N= 77 74 78 

Figure 6. Outpatient Overall Quality 

7

 Used to restore normal heart rhythm to patients in cardiac arrest. 

VA Office of Inspector General 22 
 

 

 

 

 

CBOC Reviews: Benton Harbor & Grand Rapids, MI; Terre Haute & Bloomington, IN; Yale & Pontiac, MI 

Trip 

Pati

2008 SH

YTD 

P

e

EP Perfor

T

ak Report

nt Percept

mance M

hrough September 

ions of C

easures 

2008 

 - STA5 Level 

are 

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) 

553 Detroit Mean 

Score 

66.5 57 72 79.3 77.3 

N= 92 68 65 2,210 55,407 

553GA Yale 92.3 84.3 93.7 

N= 87 77 77 

553GB Pontiac 86.6 89 93.7 

. N= 83 81 83 

Figure 7. Provider Wait Times 

Both CBOCs exceeded the parent facility’s target scores for “overall quality” and 

“provider wait times,” scoring greater than 77 percent for all quarters. 

CBOC Contract 

The contracts for the Yale and Pontiac CBOCs are administered through the Detroit 

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

continuity of care for all eligible veterans in VISN 11. 

Yale CBOC 

Contracted services with the Port Huron Hospital began on October 1, 2007, with option 

years extending through September 30, 2012. The current contract is administered under 

the provisions of Option Year 1 for the period October 1, 2008, through September 30, 

2009. The contract terms state that the CBOC will operate this clinic with a project 

director, physician licensed in Michigan, and other primary care providers including 

physicians’ assistants and nurse practitioners. The contractor is compensated by the 

number of enrollees at a current capitated rate of $41.88 per month, per enrollee. The 

CBOC had 3,015 unique enrollees with 7,634 visits as for the period October 1, 2007, 

through September 30, 2008. 

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

invoices submitted, and supporting information and performed inquiries of key VAMC 

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

quarter of 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. Veterans were enrolled through the VAMC and tracked through 

the PCMM. For the period October 1 through December 31, 2008, the number of 

VA Office of Inspector General 23 
CBOC Reviews: Benton Harbor & Grand Rapids, MI; Terre Haute & Bloomington, IN; Yale & Pontiac, MI 

invoiced enrollees exceeded the contract estimate of 3,250 by approximately 90 to 149 

enrollees. 

We also 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. 

Pontiac CBOC 

Contracted services with the Pontiac Osteopathic Hospital began on July 1, 2004, with 

option years extending through June 30, 2009. The current contract is administered 

under the provisions of contract modification number 8 for the period July 1, 2008, 

through June 30, 2009. The contract terms state that the CBOC will operate this clinic 

with a project director, physician licensed in Michigan, and other primary care providers 

including physicians’ assistants and nurse practitioners. The contractor is compensated 

by the number of enrollees at a current capitated rate of $41.53 per month, per enrollee. 

The CBOC had 3,004 unique enrollees with 5,987 visits for the period October 1, 2007, 

through September 30, 2008. 

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

invoices submitted, and supporting information and performed inquiries of key 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. Veterans were enrolled through the VAMC and tracked through the PCMM. 

For the period October 1 through December 31, 2008, the number of invoiced enrollees 

exceeded the contract estimate of 2,750 enrollees by 922 to 947 enrollees. 

We also 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. 

Pontiac and Yale CBOCs 

We noted the following: 

A. The Pontiac contractor over-billed the VAMC the annual capitated rate for an 

enrollee for the period October through December 2008. This duplicate billing 

resulted in an overpayment of $124.59 for Primary Care Services. 

B. The Yale contractor over-billed the VAMC $17,230 for the period November 1, 

2008, through April 30, 2009 due to use of an incorrect monthly capitated rate. 

The contractor incorrectly billed the monthly capitated rate of $42.72/enrollee 

applicable for the period October 1, 2009 through September 30, 2010, instead of 

VA Office of Inspector General 24 
CBOC Reviews: Benton Harbor & Grand Rapids, MI; Terre Haute & Bloomington, IN; Yale & Pontiac, MI 

using the correct rate of $41.88/enrollee for the period October 1, 2008, through 

September 30, 2009. 

C. The Yale contractor over-billed the VA for duplications in primary care enrollees 

on invoices for the period October, 2008 through December 2008. The number of 

duplicate enrollees is as follows: October (13), November (13) and December 

(16). The approximate amount of the overpayment for the period October, 2008 

through December, 2008 is 42 months times $41.88, totaling $1,759. The COTR 

should determine if there were overbillings in prior periods. 

D. The contracts do not contain a provision for disenrollment of veterans who had not 

received services at the CBOC within the prior 12 months. The absence of this 

contract provision could result in the VAMC compensating contractors even 

though no services were provided to enrollees. 

E. The VAMC COTR for the Pontiac and Yale CBOCs had initiated a project to 

identify enrollees who were being invoiced to VAMC but had not received service 

within the last 24 months or who were deceased. As of the date of this report, this 

project was ongoing and results cannot be quantified at this time. 

F. Tools were not available to the COTR to adequately review the invoices on a 

timely basis and verify that the number of enrollees was accurate. 

Recommendation 18. We recommended that the VISN 11 Director ensure that the 

Detroit VA Medical Director recovers the overcharges for the duplicate billings from the 

vendor. Additionally, any future contracts should contain a provision for disenrollment 

of veterans who have not received services at the CBOC within the prior 12 months. 

The VISN and Medical Center Directors concurred with our finding and 

recommendation. The medical center has initiated recovery of overcharges from the 

contractor and has made the appropriate provisions to the contract as addressed in our 

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

planned actions until they are completed. 

VA Office of Inspector General 25 
 

CBOC Reviews: Benton Harbor & Grand Rapids, MI; Terre Haute & Bloomington, IN; Yale & Pontiac, MI 

Appendix A 

VISN 11 Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: July 28, 2009 

From: Director, Veterans Integrated Service Network (10N11) 

Subject: Healthcare Inspection – CBOC Reviews: Benton Harbor and 

Grand Rapids, MI; Terre Haute and Bloomington, IN; and 

Yale and Pontiac, MI 

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

Healthcare Inspections (54F) 

Battle Creek, Detroit and Indianapolis’ responses to the 

 recommendations are included in this report. If you have any 

 questions, please contact Kelley Sermak, Acting QMO at 

(734) 222-4302. 

Michael S. Finegan 

VA Office of Inspector General 26 
 

CBOC Reviews: Benton Harbor & Grand Rapids, MI; Terre Haute & Bloomington, IN; Yale & Pontiac, MI 

Appendix B 

Battle Creek Medical Center Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: July 24, 2009 

From: Director, Battle Creek VA Medical Center, Battle Creek, 

MI (515/00) 

Subject: Healthcare Inspection – CBOC Reviews: Benton Harbor and 

Grand Rapids, MI 

To: Director, Veterans Integrated Service Network (10N11) 

Attached are the Battle Creek Medical Center Director’s 

comments to the Office of Inspector General’s report on 

 Healthcare Inspection, Community Based Outpatient Clinic 

reviews. 

 (original signed by:) 

SUZANNE M. KLINKER 

VA Office of Inspector General 27 
 

CBOC Reviews: Benton Harbor & Grand Rapids, MI; Terre Haute & Bloomington, IN; Yale & Pontiac, MI 

Battle Creek Medical Center 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 11 Director ensure 

that the Battle Creek VA Medical Center Director requires all background 

checks be accomplished in accordance to VHA policy. 

Concur Target Completion Date: 9-30-09 

Proof of Background Investigation for Transfer Employees. A process has 

been implemented that all employees who transfer to the Battle Creek VA 

Medical Center or its Community Based Outpatient Clinics (CBOC) will 

require proof of background investigation (ie receipt of Certificate of 

Investigation from losing station) during the pre-employment stages. If one 

cannot be provided by the losing station, Battle Creek will initiate on the 

employee’s first day. This item has been added to the local Screening 

Checklist form, which is completed on all boarding employees. This 

process will be written into Medical Center Memorandum 05-1035, 

Employee Suitability and Security Investigations, due for republication 

September 2009. 

Investigative Cases Closed Incomplete by OPM. A process has been 

implemented that when notification of closed case is received by Human 

Resources Management Service, the date received is recorded in the 

Suitability Worksheet by the Human Resource Quality Management 

Specialist. If necessary, OPM is contacted to inquire on specific reason for 

return. The case is then forwarded to Human Resource Processing and 

Records to contact the employee to obtain missing information (i.e., 

personal data, fingerprint resubmission, etc.). Once obtained, the 

information is returned to the Human Resource Quality Management 

Specialist, recorded into the Suitability Worksheet and returned to OPM to 

reopen/continue the investigation. Review of dates for incomplete 

investigations in Suitability Tracker is accomplished by the Human 

Resource Quality Management Specialist on a weekly basis. 

VA Office of Inspector General 28 
 

 

 

CBOC Reviews: Benton Harbor & Grand Rapids, MI; Terre Haute & Bloomington, IN; Yale & Pontiac, MI 

Recommendation 2. We recommended that the VISN 11 Director ensure 

that the Battle Creek VA Medical Center Director requires auditory privacy 

be maintained during the check-in process. 

Concur Target Completion Date: 7-23-09 

The following actions have been implemented at the Benton Harbor CBOC 

to increase the auditory privacy of veterans during the check-in process: 1) 

The waiting room seating has been rearranged and seats are no longer 

located next to the check-in area, 2) The clinic has revised the check-in 

process to decrease the amount of patient information that is verbally 

shared. 

Recommendation 3. We recommended that the VISN 11 Director ensure 

that the Battle Creek VA Medical Center Director implements a panic 

alarm system at the Benton Harbor CBOC. 

Concur Target Completion Date: 8-6-09 

The Battle Creek VA Medical Center will be obtaining personal alarm 

devices for all staff members at the Benton Harbor CBOC. The Loud-Key 

Safety Alarm has a 110+ decibel alarm, safety light beam, key ring, chain 

and attaching clip. These devices can be used and heard throughout the 

clinic and immediate outside area. These devices will provide staff an 

additional emergency system in addition to the use of the local 911 

emergency system. 

Recommendation 4. We recommended that the VISN 11 Director ensure 

that the Battle Creek VA Medical Center Director recovers the overcharges 

for the duplicate billings from the vendor. Additionally, any future 

contracts should contain a provision for contractor billing on a monthly 

basis to reduce the charges to the VA when contracts are terminated. 

Concur Target Completion Date: 7-23-09 

The Battle Creek VA Medical Center CBOC Coordinator has contacted CR 

Associates, the contractor, about the three over-billed primary care 

enrollees. The Battle Creek VAMC has issued a bill of collection to CR 

Associates in the amount of $999.00. Additionally, one mental health 

patient was identified as an overbill. CR Associates has been issued a bill of 

collection in the amount of $721.08. 

VA Office of Inspector General 29 
CBOC Reviews: Benton Harbor & Grand Rapids, MI; Terre Haute & Bloomington, IN; Yale & Pontiac, MI 

Appendix C 

Indianapolis Medical Center Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: July 27, 2009 

From: Director, Richard L. Roudebush VA Medical Center, 

Indianapolis, IN (583/00) 

Subject: Healthcare Inspection – CBOC Reviews: Terre Haute and 

Bloomington, IN 

To: Director, Veterans Integrated Service Network (10N11) 

The medical center has reviewed the draft report and 

concurs with all but one recommendation related to the 

review of the Terre Haute and Bloomington CBOCs. 

Corrective action plans have been developed and in the 

process of being implemented with completion by 

September 30, 2009. Explanation for the 

recommendation not in concurrence has been provided. 

Thomas Mattice 

VA Office of Inspector General 30 
 

 

 

CBOC Reviews: Benton Harbor & Grand Rapids, MI; Terre Haute & Bloomington, IN; Yale & Pontiac, MI 

Indianapolis Medical Center 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 5. We recommended that the VISN 11 Director ensure 

that the Indianapolis VA Medical Center Director requires that clinical 

managers grant privileges that are consistent with providers’ practices and 

ensure that the minutes of the PSB appropriately reflect documents 

reviewed and actions taken. 

Concur Target Completion Date: August 28, 2009 

Review with the CBOC providers confirmed that none were performing 

clinical procedures that required privileges not currently granted. A revised 

clinical privilege form for the CBOC will be presented at the next 

Executive Committee of the Medical Staff for approval. The medical 

center will administratively remove the suturing of lacerations privilege 

from the current providers privilege delineation and send them notice of 

this action. Regarding documentation in the meeting minutes, the medical 

center will be developing separate Professional Standards Board meeting 

minutes documenting the actions for the CBOC Advanced Practice Nurses. 

Recommendation 6. We recommended that the VISN 11 Director ensure 

that the Indianapolis VA Medical Center Director requires that the 

monitoring of prescriptive authority is consistently accomplished, reports 

are forwarded to the credentialing office, and results are used during the reprivileging processes. 

Concur Target Completion Date: August 1, 2009 

The Credentialing Office has instituted a process to contact any Nurse 

Practitioner, prior to their renewal date, who are delinquent in submitting 

quarterly reports of collaborator medical record reviews. If non-compliant, 

the Credentialing Office will notify the Service Chief for action. 

Recommendation 7. We recommended that the VISN 11 Director ensure 

that the Indianapolis VA Medical Director requires clinical managers 

VA Office of Inspector General 31 
 

 

 

 

CBOC Reviews: Benton Harbor & Grand Rapids, MI; Terre Haute & Bloomington, IN; Yale & Pontiac, MI 

maintain protected patient information in a secure fashion and monitor 

appropriate shredding practices. 

Concur Target Completion Date: August 1, 2009 

CBOC staff will receive training on maintaining protected patient 

information. Orientation to the number and location of shredders will be 

conducted with education for staff to utilize for all documents containing 

patient information. Environment of Care Rounds (EOC) will be conducted 

in a similar manner as in the parent facility including inspection for 

appropriate storage and disposal of patient confidential information. 

Recommendation 8. We recommended that the VISN 11 Director ensure 

that the Indianapolis VA Medical Director requires that clinicians order and 

provide emergency medications according to the terms of their contracts, 

appropriately document medications ordered for short-term use in CPRS, 

and monitor documentation of the appropriate process. 

Concur Target Completion Date: August 1, 2009 

The dispensing of all outpatient medications has been halted in the CBOCs. 

Short term prescriptions will be written to be filled at an outside pharmacy 

as per the current contract. Staff has been educated on entering these 

prescriptions under the outside VA medication option in CPRS. A list of 

medications only to be dispensed in clinic for urgent needs has been 

developed. These medications will be monitored as per Joint Commission 

standards with administration to be documented in CPRS. 

Recommendation 9. We recommended that the VISN 11 Director ensure 

that the Indianapolis VA Medical Director conduct a security risk 

assessment and evaluate the assessment to determine appropriate measures 

to take at both CBOCs. 

Concur Target Completion Date: September 30, 2009 

Police Service will conduct a security risk assessment, and the medical 

center will evaluate the assessment to determine appropriate measures. 

Recommendation 10. We recommended that the VISN 11 Director ensure 

that the Indianapolis VA Medical Director requires that patients in 

wheelchairs or with other assistive devices have proper access to the Terre 

Haute and Bloomington CBOCs. 

Concur Target Completion Date: September 30, 2009 

VA Office of Inspector General 32 
 

 

CBOC Reviews: Benton Harbor & Grand Rapids, MI; Terre Haute & Bloomington, IN; Yale & Pontiac, MI 

Door bells will be installed that are accessible to wheel chair patients at the 

entrances. The current contract for the existing site will be expiring within 

the next 3 months with probability of new space being leased. Automatic 

door openers would be cost prohibitive; however the addition of the door 

bells will allow the contractor staff to provide prompt assistance to 

handicapped patients. Language will be considered for the next iteration of 

the CBOC contract. 

Recommendation 11. We recommended that the VISN 11 Director ensure 

that the Indianapolis Medical VA Director requires clinic managers to 

assess the need for an emergency box and to maintain its contents 

appropriately if one is deemed necessary. 

Concur Target Completion Date: August 1, 2009 

The need for emergency boxes was discussed with the CBOC clinic 

managers and it was agreed that the boxes should be maintained for 

emergency treatment pending transportation to the closest emergency room. 

Medication expiration dates and inventory will be conducted according to 

Joint Commission standards on a regular basis. This will be documented in 

a log on the cart with initials of person conducting the inventory. 

Recommendation 12. We recommended that the VISN 11 Director ensure 

that the Indianapolis VA Medical Director recovers the overcharges from 

the vendor and that future invoices are verified for compliance with 

contract provisions. 

Concur Target Completion Date: September 30, 2009 

The overcharges have been brought to the attention of the contractor who 

has initiated repayment. To date 66% of the overcharges have been 

recovered with the remaining to be recovered before 9/30/2009. 

VA Office of Inspector General 33 
CBOC Reviews: Benton Harbor & Grand Rapids, MI; Terre Haute & Bloomington, IN; Yale & Pontiac, MI 

Appendix D 

Detroit Medical Center Director Comments 

Department of 

Veterans Affairs Memorandum 

Date:	 July 27, 2009 

From:	 Director, John D. Dingell VA Medical Center, Detroit, MI 

(553/00) 

Subject: Healthcare Inspection – CBOC Reviews: Yale and Pontiac, 

MI 

To:	 Director, Veterans Integrated Service Network (10N11) 

1.	 I would like to take the opportunity to thank the OIG team for 

their insight in reviewing our CBOCs in Yale and Pontiac, 

Michigan. 

2. We have reviewed each recommendation and developed a plan of 

action that will meet the intent of the associated recommendation. 

Each plan will be implemented expeditiously and thoroughly 

monitored to satisfactory completion. 

Pamela Reeves, M.D. 

VA Office of Inspector General 34 
 

 

CBOC Reviews: Benton Harbor & Grand Rapids, MI; Terre Haute & Bloomington, IN; Yale & Pontiac, MI 

Detroit Medical Center 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 13. We recommended that the VISN 11 Director ensure 

that the Detroit VA Medical Center Director requires that all LIPs are 

privileged for procedures provided at CBOCs as required by VHA. 

Concur Target Completion Date: 7/13/09 

The privileging forms for both CBOC’s were approved at a special PSB 

meeting on June 18, 2009 and then forwarded to all LIP’s in the CBOC’s 

for completion. The Professional Standards Board met on July 13, 2009 to 

recommend approval of requested privileges and review of scope of 

practices for both Yale and Pontiac CBOC’s. Provider specific data 

(measures) was used in the granting of privileges and scope of practices. 

For those that were not placed on a FPPE (Focus Professional Practice 

Evaluation), an Ongoing Professional Practice Evaluation (OPPE) will be 

conducted every 6 months as it is being done for all active practitioners 

credentialed to meet The Joint Commission regulations and VHA policies. 

Recommendation 14. We recommended that the VISN 11 Director ensure 

that the Detroit VA Medical Center Director requires that provider-specific 

performance measure data is included in the reprivileging process for both 

CBOCs as required by VA policy. 

Concur Target Completion Date: 7/13/09 

Provider specific data (measures) was used in the granting of privileges and 

scope of practices. For those that were not placed on a Focus Professional 

Practice Evaluation (FPPE), an Ongoing Professional Practice Evaluation 

(OPPE) will be conducted every 6 months as it is being done for all active 

practitioners credentialed to meet The Joint Commission regulations and 

VHA policies. 

Recommendation 15. We recommended that the VISN 11 Director ensure 

that the Detroit VA Medical Center Director requires that all medications 

VA Office of Inspector General 35 
 

 

 

 

CBOC Reviews: Benton Harbor & Grand Rapids, MI; Terre Haute & Bloomington, IN; Yale & Pontiac, MI 

accessible to patients receiving care at CBOCs are secured when 

unattended. 

Concur	 Target Completion Date: 6/3/09 

The Podiatrist rents space, as part of the Family Practice Clinic, and had 

completed seeing a patient at time of OIG visit. This action was resolved 

by the Manager, who spoke to the Podiatrist to assure medication is stored 

when not in use and disposed of after use in proper receptacle. 

Recommendation 16. We recommended that the VISN 11 Director ensure 

that the Detroit VA Medical Center Director requires that all instruments 

accessible to CBOC staff and patients receiving care at CBOCs are covered 

and secured when not in use or unattended. 

Concur	 Target Completion Date: 6/3/09 

This action was resolved. The Podiatrist was instructed to properly store 

medical instruments after use to ensure a safe clinical environment for all 

clinic patients. 

Recommendation 17. We recommended that the VISN 11 Director ensure 

that the Detroit VA Medical Center Director requires that each CBOC have 

an emergency management policy relevant to the specific needs and 

resources of each CBOC. 

Concur	 Target Completion Date: 5/27/09 for 

 Yale and 7/22/09 for Pontiac 

Both CBOC’s site did revise their emergency management policy to 

include the AED’s and medication guidelines. 

Recommendation 18. We recommended that the VISN 11 Director ensure 

that the Detroit VA Medical Center Director recovers the overcharges for 

the duplicate billings from the vendor. Additionally, any future contracts 

should contain a provision for disenrollment of veterans who have not 

received services at the CBOC within the prior 12 months. 

Concur	 Target Completion Date: 7/27/2009 

Fiscal and the COTR prepared bill of collections for the overcharges for 

duplicate billings by the Yale CBOC for 13 patients for October and 

November of 2008 and 16 patients for December 2008. Pontiac CBOC 

overbilled for one patient at 41.53 per month for 3 months. The bill of 

collections is being sent out by Fiscal 7/27/09 to both CBOC’s. 

VA Office of Inspector General 36 
 

 

CBOC Reviews: Benton Harbor & Grand Rapids, MI; Terre Haute & Bloomington, IN; Yale & Pontiac, MI 

Concur Target Completion Date: 7/6/09 

Overpayment of $17,230.92 to Yale CBOC, due to contractor using the 

incorrect capitation for the months of December 2008 to April 2009, was 

received 7/6/09. The contractor incorrectly applied the capitated rate 

applicable for the period of 10/1/09 – 9/30/10 option year for the billings 

during the period 11/09-4/30/09. 

Concur Target Completion Date: 8/21/09 

The Contract Officer will modify the current contract for both the Pontiac 

and Yale CBOC’s to include the requirement that established patients who 

were not seen by their PCP or Associate Provider within 12 months of the 

last visit will not be invoiced until they are seen by a provider. 

VA Office of Inspector General 37 
 

 

CBOC Reviews: Benton Harbor & Grand Rapids, MI; Terre Haute & Bloomington, IN; Yale & Pontiac, MI 

Appendix E 

CBOC Characteristics 

CBOC Station NumberCBOC NameParent VALaboratory(draw blood) OnsiteRadiologyOnsitePharmacyEKGSocialServicesTele-medicine 

515GC Benton Harbor Battle Creek Yes No No Yes Yes No 

515BY Grand Rapids Battle Creek Yes Yes Yes Yes Yes No 

583GA Terre Haute Indianapolis No Yes No Yes No No 

583GB Bloomington Indianapolis No Yes No Yes No No 

553GA Yale Detroit Yes Yes Yes Yes No No 

553GB Pontiac Detroit Yes Yes No Yes No No 

Onsite Services 

CBOC Station NumberCBOC NameParent VAMental HealthCarePsychologistPsychiatristNursePractitionerSocial Worker SocialServicesSpecialistTele-mentalHealth 

515GC Benton Harbor Battle Creek Yes No Yes No Yes No Yes 

515BY Grand Rapids Battle Creek Yes Yes Yes Yes Yes No No 

583GA Terre Haute Indianapolis Yes No No No Yes Yes No 

583GB Bloomington Indianapolis Yes No No No Yes Yes No 

553GA Yale Detroit Yes No No Yes No No Yes 

553GB Pontiac Detroit Yes No No Yes No No Yes 

Mental Health Services 

CBOC StationNumberCBOC NameInternalMedicinePhysicianPrimary Care Physician NursePractitionerPhysicianAssistant RegisteredNurseLPNPsychologist PharmacistSocial WorkerDietary Technician/TechnologistsAdministrative/ Clerical Other 

515GC Benton 

Harbor 

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

515BY Grand 

Rapids 

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

583GA Terre Haute Yes No Yes No Yes Yes No No Yes No No Yes No 

583GB Bloomington Yes No Yes No Yes Yes No No No No No Yes No 

553GA Yale No Yes Yes Yes Yes No No No No No No No Yes 

553GB Pontiac No Yes Yes Yes No No No No No No No No Yes 

Disciplines Present at the CBOC 

VA Office of Inspector General 38 
CBOC Reviews: Benton Harbor & Grand Rapids, MI; Terre Haute & Bloomington, IN; Yale & Pontiac, MI 

Appendix E 

CBOC Station NumberCBOC NameParent VAUrban/RuralMiles to ParentFacilityBusTaxiVoluntaryServicesTele-Medicine 

515GC Benton Harbor Battle Creek Rural 68 No Yes Yes No 

515BY Grand Rapids Battle Creek Urban 66 Yes Yes Yes No 

583GA Terre Haute Indianapolis Rural 80 No Yes Yes No 

583GB Bloomington Indianapolis Rural 60 No Yes Yes No 

553GA Yale Detroit Rural 70 Yes Yes No No 

553GB Pontiac Detroit Urban 30 Yes Yes No No 

Type of Location, Availability of Public 

Transportation, and Participation in Tele-Medicine 

VA Office of Inspector General 39 
 

 

 

CBOC Reviews: Benton Harbor & Grand Rapids, MI; Terre Haute & Bloomington, IN; Yale & Pontiac, MI 

Appendix F 

Quality of Care Measures 

Battle Creek VAMC – Benton Harbor and Grand Rapids 

Measure Facility Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 Percentage 

Hyperlipidemia 

Screen 

National 13,148 13,587 97 

515 Battle Creek 105 105 100 

515BY Grand Rapids 40 41 98 

515GC Benton Harbor 15 15 100 

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 

515 Battle Creek 38 41 93 

515BY Grand Rapids 43 47 91 

515GC Benton Harbor 6 6 100 

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 

515 Battle Creek 38 41 93 

515BY Grand Rapids 43 47 91 

515GC Benton Harbor 6 6 100 

Foot Pedal Pulses, FY 2009 

Sensory Exam 

DM - Outpatient - Foot 

Sensory Exam Using 

Monofilament 

National 5,266 5,951 88 

515 Battle Creek 38 41 93 

515BY Grand Rapids 43 47 91 

515GC Benton Harbor 6 6 100 

Foot Sensory, FY 2009 

VA Office of Inspector General 40 
 

 

 

CBOC Reviews: Benton Harbor & Grand Rapids, MI; Terre Haute & Bloomington, IN; Yale & Pontiac, MI 

Measure Meets 

Target 

Facility Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 

Percentage 

DM – Retinal 

Eye Exam 

88 National 4,599 5,258 87 

88 515 Battle Creek 34 39 87 

515BY Grand 

Rapids 

42 48 86 

515GC Benton 

Harbor 

5 6 83 

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 

95 515 Battle Creek 20 20 100 

515BY Grand 

Rapids 

47 48 98 

515GC Benton 

Harbor 

6 6 100 

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 

93 515 Battle Creek 39 39 100 

515BY Grand 

Rapids 

48 48 100 

515GC Benton 

Harbor 

6 6 100 

Renal Testing, FY 2009 

VA Office of Inspector General 41 
 

 

 

CBOC Reviews: Benton Harbor & Grand Rapids, MI; Terre Haute & Bloomington, IN; Yale & Pontiac, MI 

Appendix G 

Quality of Care Measures 

Indianapolis VAMC – Terre Haute and Bloomington 

Measure Facility 

Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 Percentage 

Hyperlipidemia 

Screen 

National 13,148 13,587 97 

583 Indianapolis 97 100 97 

608GA Terre Haute 42 42 100 

608GB Bloomington 39 40 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 

583 Indianapolis 49 49 100 

583GA Terre Haute 43 45 95 

583GB Bloomington 41 42 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 

583 Indianapolis 48 49 98 

5838GA Terre Haute 42 45 93 

583GB Bloomington 42 42 100 

Foot Pedal Pulses, FY 2009 

Sensory Exam 

DM - Outpatient - Foot 

sensory exam using 

monofilament 

National 5,266 5,951 88 

583 Indianapolis 48 48 100 

583GA Terre Haute 44 45 97 

583GB Bloomington 41 42 98 

Foot Sensory, FY 2009 

VA Office of Inspector General 42 
 

CBOC Reviews: Benton Harbor & Grand Rapids, MI; Terre Haute & Bloomington, IN; Yale & Pontiac, MI 

Measure Meets 

Target 

Facility Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 

Percentage 

DM – Retinal 

Eye Exam 

88 National 4,599 5,258 87 

88 583 Indianapolis 33 36 92 

583 GA Terre Haute 42 45 93 

583 GB Bloomington 39 42 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 

95 583 Indianapolis 36 36 100 

583 GA Terre Haute 44 45 98 

583 GB Bloomington 42 42 100 

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 

93 583 Indianapolis 36 36 100 

583GA Terre Haute 45 45 100 

583GB Bloomington 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 

90 583 Indianapolis 12 12 100 

583 GA Terre Haute 14 14 100 

583GA Bloomington 4 5 80 

PTSD Screening, FY 2009 

VA Office of Inspector General 43 
 

 

 

CBOC Reviews: Benton Harbor & Grand Rapids, MI; Terre Haute & Bloomington, IN; Yale & Pontiac, MI 

Appendix H 

Quality of Care Measures 

Detroit VAMC – Yale and Pontiac 

Measure Facility 

Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 Percentage 

Hyperlipidemia 

Screen 

National 13,148 13,587 97 

553 Detroit 100 103 97 

553GA Yale 47 47 100 

553GB Pontiac 48 48 100 

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 

553 Detroit 52 54 96 

553GA Yale 44 45 98 

553GB Pontiac 46 48 96 

DM Foot Inspection, FY 2009 

 Measure Facility Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 Percentage 

DM - Outpatient Foot 

pedal pulses 

National 5,395 5971 90 

553 Detroit 52 54 96 

553GA Yale 44 45 98 

553GB Pontiac 47 48 98 

Foot Pedal Pulses, FY 2009 

Sensory Exam 

DM - Outpatient - Foot 

Sensory Exam Using 

Monofilament 

National 5266 5951 88 

553 Detroit 51 54 94 

553GA Yale 44 45 98 

553GB Pontiac 47 48 98 

Foot Sensory, FY 2009 

VA Office of Inspector General 44 
 

 

 

CBOC Reviews: Benton Harbor & Grand Rapids, MI; Terre Haute & Bloomington, IN; Yale & Pontiac, MI 

Measure Meets 

Target 

Facility Qtr 1 

Numerator 

Qtr 1 

Denominator 

Qtr 1 

Percentage 

DM – 

Retinal Eye 

Exam 

88 National 4,599 5,258 87 

553 Detroit 41 48 85 

553GA Yale 44 45 98 

553GB Pontiac 35 48 73 

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 

553 Detroit 44 48 92 

553GA Yale 45 45 100 

553GB Pontiac 45 48 94 

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 

553 Detroit 46 48 96 

553GA Yale 44 45 98 

553GB Pontiac 46 48 96 

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 

553 Detroit 24 25 96 

553GA Yale 15 17 88 

553GB Pontiac 9 9 100 

PTSD Screening, FY 2009 

VA Office of Inspector General 45 
CBOC Reviews: Benton Harbor & Grand Rapids, MI; Terre Haute & Bloomington, IN; Yale & Pontiac, MI 

Appendix I 

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 

Lin Clegg, Ph.D. 

Marnette Dhooghe, MS 

Kathy Gudgell, RN, JD 

Stephanie Hensel, RN, JD 

Anthony M. Leigh, CPA, CFE 

Annette Robinson, MSN, MBA, HCM 

Tom Seluzicki, CPA, CFE 

Marilyn Stones 

Marilyn Walls, RN, MS, CPHQ 

VA Office of Inspector General 46 
CBOC Reviews: Benton Harbor & Grand Rapids, MI; Terre Haute & Bloomington, IN; Yale & Pontiac, MI 

Appendix J 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, Veterans Integrated Service Network (10N11) 

Director, Battle Creek VA Medical Center (515/00) 

Director, Richard L. RoudebushVA Medical Center (583/00) 

Director, John D. Dingell VA Medical Center (553/00) 

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: Evan Bayh, Carl Levin, Richard G. Lugar, Debbie Stabenow 

U.S. House of Representatives: Steve Buyer, Vernon J. Ehlers, Brad Ellsworth, Baron 

Hill, Thaddeus McCotter, Candice Miller, Gary Peters, Fred Upton 

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

VA Office of Inspector General 47