Department of Veterans Affairs
 

Office of Inspector General
 

Healthcare Inspection
 

Patient Safety Issues
 

VA Caribbean Healthcare System
 

San Juan, Puerto Rico
 

Report No. 09-03055-103 March 16, 2010
 VA Office of Inspector General
 

Washington, DC 20420
 
To Report Suspected Wrongdoing in VA Programs and Operations: 

Telephone: 1-800-488-8244 

E-Mail: vaoighotline@va.gov
 

(Hotline Information: http://www4.va.gov/oig/contacts/hotline.asp)
 
Patient Safety Issues, VA Caribbean Healthcare System, San Juan, PR 

Executive Summary
 

The VA Office of Inspector General, Office of Healthcare Inspections received 

allegations regarding quality of care and patient safety related to the reprocessing of 

reusable medical equipment (RME) at the VA Caribbean Healthcare System (the system) 

in San Juan, Puerto Rico. 

A complainant alleged that transvaginal ultrasound transducer equipment was not 

properly disinfected at the Mayaguez outpatient clinic (OPC), and that leak tests were not 

performed on endoscopes in three other areas in the system. The complainant also 

alleged that the system inaccurately reported compliance with RME reprocessing 

procedures and training requirements and ignored evidence and warnings of unsafe 

practices in reprocessing RME since February 2009. 

We substantiated the allegation that endovaginal transducers at the Mayaguez OPC were 

not submitted to high-level disinfection as required after each patient procedure for 

approximately 2 years. We also learned the same condition existed at the hospital in San 

Juan. 

We substantiated the allegation that leak testing was not performed on colonoscopes in 

the Operating Room for at least 9 months or on laryngoscopes in Radiotherapy and at the 

Ponce OPC for 9 months and 3 years respectively. We also learned that pre-cleaning was 

improperly performed on the laryngoscopes in Radiotherapy and one of the 

laryngoscopes had a leak while it was in service during this time. 

We substantiated the allegation that the system inaccurately certified compliance with 

RME reprocessing procedures and training on three occasions. We also substantiated the 

allegation that senior system leadership and responsible managers were aware of these 

issues but took no action to assess the risk to patients. 

As a result of our review, issue briefs (IB) on each area were discussed on pre-CRAAB 

(Clinical Risk Assessment Advisory Board) conference calls. Based on information 

provided by the system, the risk to patients was determined to be negligible. As 

information about inadequate pre-cleaning of laryngoscopes in Radiotherapy was not 

included in the IB, this issue should receive further review. An Administrative 

Investigation Board (AIB) was completed after our visit to address management 

responsiveness. 

We recommended that an appropriate risk assessment, based upon findings of improper 

laryngoscope cleaning in Radiotherapy, be performed and appropriate actions taken. We 

also recommended that the VISN Director follow up on all recommendations from the 

AIB and take appropriate administrative action. 

VA Office of Inspector General i 
DEPARTMENT OF VETERANS AFFAIRS
 

Office of Inspector General
 

Washington, DC 20420
 

TO: Director, VA Sunshine Healthcare Network (10N8) 

SUBJECT: Healthcare Inspection – Patient Safety Issues, VA Caribbean Healthcare 

System, San Juan, Puerto Rico 

Purpose 

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

an inspection to determine the validity of allegations regarding quality of care and patient 

safety related to the reprocessing of reusable medical equipment (RME) at the VA 

Caribbean Healthcare System (the system) in San Juan, Puerto Rico. 

Background 

The system includes a tertiary care facility, the San Juan VA Medical Center (hereafter 

referred to as the hospital) in San Juan, with Community Based Outpatient Clinics in 

Arecibo, Guayama, and the U.S. Virgin Islands. There are satellite outpatient clinics 

(OPC) located in Mayaguez and Ponce. The system is part of Veterans Integrated 

Service Network (VISN) 8. 

RME reprocessing is an area of high visibility within the VA and has received 

considerable media attention. The National Center for Patient Safety (NCPS) released 

Patient Safety Alert AL09-07, Improper Set-Up and Reprocessing of Flexible Endoscope 

Tubing and Accessories, on December 22, 2008. This alert required facilities to report 

issues they identified with incorrect set-up or failure to adequately clean or reprocess 

flexible endoscopic equipment in an Issue Brief (IB) through their network office to the 

VA Central Office. According to VHA policy,1 “clinicians and organizational leaders are 

to work together to ensure that appropriate disclosure to patients or their personal 

representatives is a routine part of the response to a harmful or potentially harmful 

adverse event.” The Deputy Under Secretary for Health for Operations and Management 

(DUSHOM) is responsible for reviewing adverse events that may require large scale 

disclosure. This process is accomplished through the Clinical Risk Assessment Advisory 

Board (CRAAB). 

1 VHA Directive 2008-002, Disclosure of Adverse Events to Patients, January 18, 2008. 

VA Office of Inspector General 1 
Patient Safety Issues, VA Caribbean Healthcare System, San Juan, PR 

The DUSHOM sent a memorandum to all facility directors on January 28, 2009, 

outlining his expectations that all sites conduct a review of their set-up and reprocessing 

procedures. VHA Directive 2009-004, Use and Reprocessing of Reusable Medical 

Equipment in VHA Facilities, which established a detailed set of procedures for RME 

reprocessing within VHA facilities, was issued on February 9. An Endoscope Step-up 

Week was held on March 9–13. VISN 8 issued an action item on April 2 that instructed 

all facilities to review directive 2009-004, and “provide the network with any questions 

or concerns which may prevent compliance.” An “Accountability” memorandum sent by 

the acting DUSHOM on June 24 emphasized the need for facility leadership to be “fully 

cognizant of VHA Directive 2009-004” and to address non-compliance with disciplinary 

action when indicated. 

The system has a task force (hereafter referred to as the system task force) that monitors 

the reprocessing of endoscopic equipment and the operation of sterilization equipment. 

System task force members conducted unannounced observations and inspections in 

areas where reprocessing occurred. Their findings resulted in corrective action plans to 

bring the system into compliance with reprocessing procedures, competencies, and 

standard operating procedures (SOP). The system task force became the RME 

Committee in June 2009. 

The OIG received allegations from a complainant, who provided more than 137 pieces of 

evidence to support allegations that: 

 Transvaginal ultrasound transducer equipment was not properly disinfected at the 

Mayaguez OPC. 

 Leak tests were not performed on endoscopes in the Radiotherapy Department and 

in the Operating Room (OR) at the hospital, or at the Ponce OPC. 

 The system inaccurately reported compliance with RME procedures and 

reprocessing and training requirements. 

 Since February 2009, system managers ignored evidence and warnings of unsafe 

practices in reprocessing RME. 

Scope and Methodology 

We conducted a site visit at the hospital August 25–28, 2009. Prior to our visit, we 

interviewed the complainant via telephone. During our site visit, we interviewed senior 

managers including the System Director, Associate Director (AD), Chief of Surgery, and 

Chief of Staff (COS). We also interviewed the Staff Assistant to the Associate Director, 

the Patient Safety Manager (PSM), and the Quality Manager (QM) who chaired the 

system task force. We also interviewed members of the system task force inspection 

team, including the Acting Chief of Infection Control, the Chief of Supply Processing 

and Distribution (SPD), a health systems specialist (HSS) in the patient safety office, and 

a HSS in the quality management office. We interviewed a biomedical engineer and 

VA Office of Inspector General 2 
Patient Safety Issues, VA Caribbean Healthcare System, San Juan, PR 

other members of the system task force and RME Committee. We interviewed several 

staff responsible for reprocessing RME, including the urology clinic supervisor, a 

registered nurse (RN) in the Radiotherapy Department ear, nose and throat (ENT) area, 

and an ENT technician. While on site, we reviewed RME Committee minutes, e-mail 

messages, Veterans Health Administration (VHA) certifications, policies, SOPs, and 

manufacturer’s instructions related to RME. We reviewed SPD inspection reports and 

VHA National SPD Quality Management Observational Assessment Tools and related 

action plans. 

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

by the President’s Council on Integrity and Efficiency. 

INSPECTION RESULTS 

Issue 1: RME Disinfection 

We substantiated the allegation that endovaginal transducers at the Mayaguez OPC were 

not subjected to high-level disinfection (HLD)2 as required after each patient procedure. 

A member of the system task force inspection team and a biomedical engineer visited the 

Mayaguez OPC on July 16, 2009, to inventory RME. They discovered that a technician 

performing endovaginal ultrasounds was not subjecting the endovaginal transducers to 

HLD. The technician who performed the endovaginal ultrasounds reported that she did 

not perform HLD on the transducers, but that she sprayed them with a disinfectant spray. 

The technician also reported that she covered the transducers with two latex sheaths 

before use. The manufacturer’s instructions, the SOPs, and the device-specific 

competency for this procedure clearly defined the requirement for HLD, including 

immersion in the disinfecting solution Cidex OPA. A system task force inspector told us 

and a clinic log confirmed that Cidex OPA solution had not been used in the clinic since 

2007. 

The members of the system task force inspection team reported the issue immediately for 

appropriate follow-up. We received a copy of an e-mail reporting this condition to senior 

managers. The Medical Director of the Mayaguez OPC cancelled endovaginal 

procedures immediately, and required that staff be re-trained by September 2009. 

When system managers were informed of the issue in Mayaguez, they determined that 

the same condition existed in the hospital and therefore stopped endovaginal ultrasound 

procedures performed there as well. However, because SPD staff were properly 

disinfecting similar equipment, managers reassigned the reprocessing of endovaginal 

transducers to SPD and resumed procedures in the hospital. 

2 Refers to the destruction of all microorganisms with the exception of high levels of bacterial spores. 

VA Office of Inspector General 3 
Patient Safety Issues, VA Caribbean Healthcare System, San Juan, PR 

System managers did not provide an IB to the VISN to review for referral to the CRAAB 

despite the fact that this condition existed for approximately 2 years. No actions were 

taken to identify patients who may have been at risk for infection. 

As a result of our review, on September 1, system managers prepared an IB for the VISN 

which stated that HLD was not done from March 2007 to July 2009 on the RME at 

Mayaguez and in the hospital. The IB was discussed on a pre-CRAAB conference call 

September 22, 2009. Although this RME was not submitted to HLD as required at either 

location, because double latex sheaths were used, the risk of exposure was considered to 

be negligible and no patients were notified. 

Issue 2: Leak Testing 

We substantiated the allegation that leak testing was not being performed in the hospital 

Radiotherapy Department and OR, or in the Ponce OPC. The RME involved included 

laryngoscopes in the Radiotherapy Department at the hospital and in the Ponce OPC, and 

colonoscopes in the hospital OR. We confirmed that these endoscopes required leak 

testing per the manufacturer’s instructions. 

Leak testing is a critical part of the cleaning phase performed after each procedure to 

ensure integrity of the external sheath of the instrument, and to prevent fluid invasion into 

internal components of the scope prior to immersion into an enzyme cleaning solution. 

This test represents an important step for infection control purposes, as leaks can 

contaminate the scope and may not allow for proper disinfection between patient 

procedures. 

Radiotherapy Department 

We confirmed that leak testing was not performed on a laryngoscope in Radiotherapy 

between October 2008 and June 26, 2009. We also learned that when the issue was 

identified, all laryngoscopes were sent to SPD for leak testing and one tested positive. 

The laryngoscope was immediately removed from service. It is not known how long the 

leak existed. We interviewed the RN who was responsible for reprocessing the 

laryngoscope, and had worked in the Radiotherapy area since October 2008. She told us 

that her orientation did not include information about the need for leak testing and she 

was never trained to perform leak tests. The RN also reported that the laryngoscope with 

the leak was the only laryngoscope used during this time period. 

System managers were unaware that laryngoscopes were in use in this area until 

June 26, 2009. Although a recommendation for review of patients potentially exposed to 

risk of infection during this 9-month period was sent by a member of the system task 

force inspection team to the PSM, the QM, the Acting Chief of Infection Control, the 

Chief of SPD and several members of the RME Committee, the review was not 

conducted. 

VA Office of Inspector General 4 
Patient Safety Issues, VA Caribbean Healthcare System, San Juan, PR 

As a result of our review, on September 1, system managers prepared an IB for the VISN 

related to the issues in Radiotherapy. The IB was discussed on a pre-CRAAB conference 

call September 22. The IB was not updated to include information that the RN did not 

follow proper cleaning procedures. Although this RME required the use of an enzymatic 

detergent in the pre-cleaning process, the RN reported that her pre-cleaning process 

consisted of rinsing the laryngoscope under running water in a hand hygiene sink and 

drying it with a clean gauze pad. Without proper pre-cleaning, adequate disinfection 

cannot be ensured. As the pre-CRAAB committee did not have all the relevant facts, the 

issue should receive further review. 

Operating Room 

We confirmed that leak testing was not performed as required on flexible colonoscopes in 

the OR. The system task force inspection team conducted an unannounced inspection in 

the OR on May 9, 2008. The follow-up action plan that was created to address 

deficiencies identified during the inspection required staff to “Perform a wet leak test 

when the F.C. [flexible colonoscope] is reprocessed.” The target date for completion was 

May 30, 2008. However, in October 2008, the system task force inspection team 

reported a deficiency in leak testing in the OR. 

On February 5, 2009, during a repeat inspection of the OR, the system task force 

inspection team again identified that leak testing was not being performed. During this 

inspection, two OR technicians were interviewed. One technician stated “we only do 

leak testing on Friday,” and the other stated “we don’t do the leak test because we are too 

busy.” Task force inspection team members did not observe leak testing equipment in 

the OR during their review. SPD supplied OR with a machine for leak testing 

immediately after this inspection. 

This issue was reported to the COS on February 12, 2009. The COS e-mailed the Chief 

of Surgery who reported that the leak testing equipment was on order since 

October 10, 2008. In the e-mail, the Chief of Surgery stressed the importance of 

conducting leak testing. During our site visit, we interviewed the Chief of Surgery to 

determine how long the OR had been without leak testing equipment prior to 

October 2008. He told us that he did not know if leak testing had ever been done. 

Although the deficiency was identified three times between May 2008 and 

February 2009, managers took no action to assess the risk to patients. 

As a result of our review, on September 1, system managers prepared an IB for the VISN. 

The IB was discussed on a pre-CRAAB conference call on September 22, 2009. The 

committee felt that the risk of bloodborne pathogen transmission due to failure to leak 

test was negligible and no patients were notified. 

VA Office of Inspector General 5 
Patient Safety Issues, VA Caribbean Healthcare System, San Juan, PR 

Ponce OPC 

We confirmed that leak testing was not performed as required on RME at the Ponce OPC 

for 3 years. The system task force inspection team visited the Ponce OPC June 18, 2009, 

to observe endoscope cleaning procedures in the Urology Clinic. During the inspection, 

it was discovered that endoscopic ENT procedures were being done in the clinic as well. 

We learned that the physician performing the procedures was reprocessing the equipment 

himself and that leak testing was not being done after procedures as required. The 

inventory list confirmed that a Karl StorzTM Laryngoscope was the only laryngoscope in 

use at the Ponce OPC, and this endoscope required leak testing. System managers took 

no action to assess the risk to patients. 

As a result of our review, on September 22, system managers prepared an IB for the 

VISN. The pre-CRAAB committee minutes read as follows: “The physician had 

reportedly been soaking the laryngoscope for 30-40 minutes in Cidex OPA; however, 

there were not any log books maintained on the use of the disinfectant.” The committee 

decided that “although the physician was not properly cleaning the laryngoscope and the 

leak testing was not being properly performed, the patient risk was negligible” and 

patients were not notified. 

Issue 3: Certifications of Compliance 

We substantiated the allegation that the system inaccurately certified compliance with 

endoscope equipment procedures, reprocessing, and training on three occasions. 

The NCPS issued a Patient Safety Alert on December 22, 2008 (AL09-07, Improper setup and reprocessing of flexible endoscope tubing and accessories), which required a 

response of compliance with reprocessing procedures from the “Facility Director (or 

designee)” by January 7, 2009. Facilities were to identify all areas in the facility where 

reprocessing of flexible endoscopes occurred, and ensure that all personnel who 

performed procedures with flexible endoscopes and/or reprocessed endoscopes and their 

tubing and accessories read the alert. In addition, facilities were required to confirm that 

reprocessing personnel had been assessed for competency, and that locally-developed 

SOPs that were in accordance with manufacturer’s instructions were in place. 

The response to the VISN was from the PSM and included an assessment of the 

gastrointestinal (GI) clinic only, instead of a system-wide review as required by the 

NCPS alert. 

The system director submitted the second certification of compliance to the VISN on 

March 19, 2009. This annual certification of endoscope processes failed to identify 

training deficiencies and locations of all endoscopic procedures to include outpatient 

clinics. 

VA Office of Inspector General 6 
Patient Safety Issues, VA Caribbean Healthcare System, San Juan, PR 

The third certification of compliance was sent to the VISN on June 5, 2009. This 

document from the system director verified that SOPs were in place for every model of 

equipment according to manufacturer’s instructions, and that competencies by direct 

observation were completed. However, a VISN staff inspection conducted in July noted 

the need for staff re-training, new SOPs, reprocessing of some equipment that had 

already been reprocessed, and development of device-specific competencies. 

Issue 4: Management Response 

We substantiated the allegation that since February 2009, system managers ignored 

warnings regarding patient safety issues concerning the reprocessing of RME. During 

our interviews, we asked system managers if any issues of concern were identified during 

the system task force inspections. They all answered that none were identified or 

reported. We were given documents showing that RME Committee members and senior 

managers were informed of the issues that are detailed in this report. Furthermore, we 

have testimony from staff that worked in these areas or were part of the system task force 

inspection team that verified the accuracy of these issues. 

One of the members of the system task force inspection team reported these issues to the 

PSM with a recommendation that a Root Cause Analysis (RCA)3 be conducted to assess 

the system failures that may have contributed to these deficiencies. The PSM verified 

that a RCA was recommended but told us she felt that a Healthcare Failure Mode and 

Effect Analysis4 would have been more appropriate. When asked why neither review had 

been performed, the PSM could offer no explanation. 

On August 25, 2009, we asked for all documents related to the VISN site visit of July 

2009, including the final report. We were told that no final report was received. The 

VISN provided us with the final report of the site visit, which was sent to the system on 

July 13. We discussed our concerns about management responsiveness with the VISN 

and System Directors and verified that an Administrative Investigation Board (AIB) 

would be chartered to further investigate and address these issues. 

Following our visit, an AIB was chartered and completed and recommended actions are 

currently under review by the VISN. 

Conclusions 

We substantiated that endovaginal transducers were not properly disinfected and that leak 

testing was not performed on endoscopes in Radiotherapy, the OR, and in the Ponce 

OPC. We substantiated that the system inaccurately certified compliance on three 

3 A process for identifying the basic or contributing causal factors that underlie variations in performance associated
 

with adverse events or close calls.
 4 A prospective assessment that identifies and improves steps in a process thereby reasonably ensuring a safe and
 

clinically desirable outcome.
 

VA Office of Inspector General 7 
Patient Safety Issues, VA Caribbean Healthcare System, San Juan, PR 

occasions. We also substantiated that senior system leadership and responsible managers 

were aware of these issues and failed to take appropriate action to determine if patient 

safety concerns were adequately addressed. 

Since our onsite review, an AIB and review of RME reprocessing by the VA SPD 

Executive Program Director have been completed. IBs were submitted for pre-CRAAB 

reviews. Based on the information provided, the pre-CRAAB committee determined the 

risk to patients to be negligible. Due to incomplete information contained in the issue 

brief, further consideration by the pre-CRAAB committee is indicated for the 

laryngoscope issue in Radiotherapy. 

Recommendations 

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

appropriate risk assessment, based upon findings of improper laryngoscope cleaning in 

Radiotherapy, be performed and appropriate actions taken. 

Recommendation 2. We recommended that the VISN Director follow up on all 

recommendations from the AIB and take appropriate administrative action. 

Comments 

The VISN and Healthcare System Directors concurred with our findings and 

recommendations and provided an acceptable action plan. See Appendixes A and B 

(pages 9-11) for the full text of the Directors’ comments. We will follow up on the 

proposed 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 8 
Patient Safety Issues, VA Caribbean Healthcare System, San Juan, PR 

Appendix A 

VISN Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: February 24, 2010 

From: Director, VA Sunshine Healthcare Network (10N8) 

Subject: Healthcare Inspection – Patient Safety Issues, VA Caribbean 

Healthcare System, San Juan, PR 

To:	 Director, St. Petersburg Office of Healthcare Inspections 

(54SP) 

Director, Management Review Office (10B5) 

1. I have reviewed and concur with the findings and 

recommendations contained in the Healthcare Inspection report, as it 

relates to Patient Safety Issues at the VA Caribbean Healthcare 

System in San Juan, PR. 

2. Appropriate action has been initiated and/or completed, as 

detailed in the attached report. 

Nevin M. Weaver, FACHE 

VA Office of Inspector General 9 
Patient Safety Issues, VA Caribbean Healthcare System, San Juan, PR 

VISN Director Comments
 

to Office of Inspector General’s Report
 

The following Director’s comments are submitted in response to the 

recommendation in the Office of Inspector General’s report: 

OIG Recommendations 

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

appropriate risk assessment, based upon findings of improper laryngoscope 

cleaning in Radiotherapy, be performed and appropriate actions taken. 

Concur: We concur that the Issue Brief did not reflect information obtained from 

the interviews conducted by the Administrative Investigation Board as it related 

to the pre-cleaning of laryngoscopes in Radiotherapy. 

Status: The Issue Brief, dated September 1, with subsequent updates of 

September 2 and September 23 did not include information from the interviews 

conducted by the Administrative Investigation Board. As a result, an update to 

the Issue Brief will be submitted to include information that may have been 

omitted from the Pre-CRAAB review that was conducted on September 22, 2009 

on this issue. 

Target Completion Date: Pending. The VISN 8 Network Director will submit 

an updated Issue Brief to appropriate VHA officials, which will reflect the 

information obtained from the interviews conducted by the Administrative 

Investigation Board, as it relates to the pre-cleaning process of the laryngoscopes 

in Radiotherapy, to ensure all information is considered in the risk assessment 

decision. 

Recommendation 2. We recommended that the VISN Director follow up on all 

recommendations from the AIB and take appropriate administrative action. 

Concur: We concur that the VISN Director has completed appropriate follow-up 

of each of the recommendations from the AIB. 

Status: An AIB team, chartered by VISN 8 completed its review and finalized the 

AIB report in December 2009. VISN 8 has forwarded the final recommendations 

to VHA OHRM and the Office of General Counsel for review and guidance on 

the appropriate actions that should be taken. 

Target Completion Date: Pending. VISN 8 is awaiting the outcome of the final 

review and recommendations from VHA OHRM and the Office of General 

Counsel as to the appropriate actions that should be taken. 

VA Office of Inspector General 10 
Patient Safety Issues, VA Caribbean Healthcare System, San Juan, PR 

Appendix B 

System Director Comments 

Department of 

Veterans Affairs Memorandum 

Date:	 February 23, 2010 

From:	 Director, VA Caribbean Healthcare System (672/00) 

Subject:	 Healthcare Inspection – Patient Safety Issues, VA Caribbean 

Healthcare System, San Juan, PR 

To: Director, VA Sunshine Healthcare Network (10N8) 

1.	 On behalf of the VA Caribbean Healthcare System, I want to express 

my appreciation to the Office of Inspector General (OIG), Office of 

Healthcare Inspections for their professional and comprehensive 

review of patient safety issues, conducted on August 25-28, 2009. 

2.	 I concur with the findings and recommendations of this Office of 

Inspector General report. The VA Caribbean Healthcare System 

welcomes the external perspective provided by this report. 

3.	 The VA Caribbean Healthcare System’s reply outlines the initiative 

already taken in response to these findings. 

Wanda Mims, MBA 

VA Office of Inspector General 11 
Patient Safety Issues, VA Caribbean Healthcare System, San Juan, PR 

Appendix C 

OIG Contact and Staff Acknowledgments 

OIG Contact	 Christa Sisterhen, Director 

St. Petersburg Regional Office of Healthcare Inspections 

(727) 395-2419 

Acknowledgments	 David Griffith 

Alice Morales-Rullan 

VA Office of Inspector General 12 
Patient Safety Issues, VA Caribbean Healthcare System, San Juan, PR 

Appendix D 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VA Sunshine Healthcare Network (10N8) 

Director, VA Caribbean Healthcare System (672/00) 

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 

Resident Commissioner for Commonwealth of Puerto Rico: Pedro Pierluisi 

Delegate to Congress from the U.S. Virgin Islands: Donna M. Christensen 

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

VA Office of Inspector General 13