Department of Veterans Affairs 

Office of Inspector General 

Healthcare Inspection 

 

Quality of Care Issues 

Clement J. Zablocki VA Medical Center 

Milwaukee, Wisconsin 

Report No. 07-00569-212 September 26, 2007

VA Office of Inspector General 

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

Call the OIG Hotline – (800) 488-8244 
Quality of Care Issues, Clement J. Zablocki VA Medical Center Milwaukee, Wisconsin 

Executive Summary 

The purpose of this inspection was to determine the validity of allegations made by an 

anonymous complainant regarding the quality of care provided to patients by a clinician 

on the Palliative Care Unit (PCU) at the Clement J. Zablocki VA Medical Center in 

Milwaukee, WI. Patients are admitted to this unit for end of life care. The complainant 

alleged that four patients were denied pain medications during the last stage of life, and 

another patient was given the wrong medication that caused the patient’s premature 

death. 

While we substantiated that a patient’s daughter expressed concerns regarding the 

patient’s condition and wanted the treatment plan changed to avoid further pain, after the 

physician explained his reason for not changing the treatment plan, the daughter agreed 

with his decision. We substantiated that a patient died before the order for a morphine 

sulfate intravenous drip was initiated and that a patient was given the wrong medication. 

However, we did not substantiate that the medication error caused this patient’s death. 

Additional PCU concerns regarding patient confidentiality and storage of hazardous 

cleaning products were identified during our on-site inspection, and managers took 

immediate action to correct these deficiencies. 

We did not substantiate that the patients named in the allegations were denied pain 

medications and allowed to suffer during the last stage of their life while on the PCU. 

Further, we did not substantiate that the clinician told a patient’s family member that the 

patient was not in pain or that a patient’s son had to convince the clinician to administer 

morphine sulfate so that his father could be comfortable during the last stage of his life. 

We made recommendations that management should ensure that: 

• All PCU staff use the Bar Code Medication Administration system when 

administering medications and all clinical disclosures are conducted according to 

Veterans Health Administration policy. 

• All PCU staff comply with patient confidentiality and computer security policies. 

• All PCU staff comply with medical center policy and Joint Commission’s 

Environment of Care Standards for storing hazardous cleaning products. 

VA Office of Inspector General i 
DEPARTMENT OF VETERANS AFFAIRS

Office of Inspector General 

Washington, DC 20420 

TO: Director, Veterans Integrated Service Network 12 (10N12) 

SUBJECT: Healthcare Inspection – Quality of Care Issues, Clement J. Zablocki VA 

Medical Center, Milwaukee, Wisconsin 

Purpose 

The purpose of this inspection was to determine the validity of allegations made by an 

anonymous complainant regarding the quality of care provided to patients by a staff 

member (hereafter identified as the clinician) on the Palliative Care1

 Unit (PCU) at the 

Clement J. Zablocki VA Medical Center (the medical center). It was alleged that four 

patients were denied pain medications during the last stage of their life. The complainant 

also alleged that a fifth patient was given the wrong medication by the clinician which 

caused the patient’s premature death.

Background 

The medical center is a tertiary care facility that is part of Veterans Integrated Service 

Network (VISN) 12 and provides a broad range of inpatient and outpatient care services 

including medical, surgical, mental health, geriatric, rehabilitation services, and spinal 

cord injury care. The medical center serves a veteran population of approximately 

235,000 in a primary service area that includes 15 counties in the eastern part of 

Wisconsin. The medical center is affiliated with the Medical College of Wisconsin and 

supports 142 medical resident positions in 34 training programs. 

An anonymous complainant contacted the Office of Inspector General Hotline with the 

following allegations regarding the quality of care provided to patients by a clinician on 

the PCU: 

• The clinician denied pain medication to patient A, allowing the patient to suffer 

for days during the last stage of his life. The family was told by the clinician that 

the patient was not in pain and could sit up in the chair. 

 

1

 Palliative care can afford relief of the pain of a patient whose disease is not responsive to curative treatment. 

VA Office of Inspector General 1 
Quality of Care Issues, Clement J. Zablocki VA Medical Center Milwaukee, Wisconsin 

• A family member of patient B had to convince staff to administer morphine sulfate 

(also referred to as MSO4, which is the chemical symbol) to regulate the patient’s 

breathing and to reduce the severe pain the patient was experiencing during the 

last stage of his life. 

• The clinician and other staff failed to administer pain medication to patient C 

during the last stage of his life. The patient’s daughter expressed concerns with 

the care her father received during his last 48 hours of his life. 

• Patient D’s son screamed and begged in despair for the clinician to order MSO4 so 

his father could be comfortable during the last stage of his life. The MSO4 drip2

was ordered, however, it arrived on the PCU after the patient died. 

• Patient E died prematurely after the clinician administered the wrong medication. 

According to the allegation, when the family asked the clinician about this error, 

they were told the medication would not harm the patient. 

Scope and Methodology 

On May 1–3, 2007, we conducted a site visit at the medical center. We interviewed 

managers and staff, and conducted an environment of care inspection of the PCU. Prior 

to the site visit, we reviewed electronic medical records for the five patients named in the 

complaint, medical center documentation, policies, and quality management data. 

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

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

Inspection Results 

Patient A Case History and Findings 

Patient A was a 77-year-old male veteran, who transferred from a community facility to 

the medical center’s medical unit on September 14, 2006, with diagnoses of lung cancer 

and pneumonia. He was transferred to the Intensive Care Unit (ICU) 2 days after 

admission for worsening respiratory status. On September 27 the patient was transferred 

to the PCU with an overall poor prognosis. Pain management orders included MSO4

5 mg sublingual (under the tongue) every hour as needed for difficult breathing or pain. 

On October 10 the patient’s pain level was scored as 8 out of a possible 10, with 10 being 

the highest pain level. He received pain medication as needed. Later, when the patient 

refused to get up in the chair, the clinician suggested that he should try to sit up as much 

 

2

 The continuous introduction of an intravenous (IV) fluid into a vein, a drop at a time. 

VA Office of Inspector General 2 
Quality of Care Issues, Clement J. Zablocki VA Medical Center Milwaukee, Wisconsin 

as possible to regain his strength. She encouraged the patient to get into a wheelchair so 

that he could visit with his wife off the unit when she arrived. The patient agreed and 

was assisted with transfer to the wheelchair. 

On the morning of October 16 the patient was noted to be very lethargic. Documentation 

shows that he had been getting medications as ordered for complaints of “pain all over.” 

Because of the patient’s lethargy and often vague complaints regarding his discomforts, 

his pain medication intervals were increased from every 1 hour to every 3 hours. At 

lunchtime, the patient was awake and eating well when fed. The patient was monitored 

closely for comfort during the next 24 hours. The care plan was to keep him comfortable 

and responsive. 

October 17, the clinician documented that the patient was agitated and moaning in 

discomfort. The patient’s wife was notified by telephone that the patient’s condition was 

deteriorating and that he would be more comfortable with a continuous MSO4 IV drip for 

pain. The wife stated that she knew this was coming and that she and other family 

members agreed with the clinician’s suggestion to begin this comfort measure. 

We did not substantiate that patient A was denied pain medications and comfort care 

during the last stage of his life or that the clinician had told the family or the patient that 

he was not in pain. 

Patient B Case History and Findings 

Patient B was a 60-year-old male veteran with a history of diabetes and morbid obesity3

who was transferred to the medical center on October 10, 2006, from a community 

facility. The patient was admitted to the ICU with hypoglycemia (low blood glucose), 

blood in his stool, and severe abdominal pain. General Surgery and Gastroenterology 

consultations were ordered on admission to the ICU. The gastroenterologist performed a 

colonoscopy on the same day. The colonoscopy identified several polyps and one large 

polyp that was actively bleeding. Biopsies were positive for adenocarcinoma, and it was 

believed that the patient was in hepatic (liver) failure. General Surgery physicians 

recognized the need for an operative intervention, but the patient’s co-morbidities (poor 

liver function, obesity, and renal insufficiency) necessitated medical clearance. The 

patient received medical clearance, and surgeons performed a partial left colon resection 

on October 13. The surgeons found the tumor had spread to the patient’s liver. The 

patient was readmitted to the ICU after surgery. On October 19 at 4:14 p.m., the patient 

was transferred to the PCU with orders for a MSO4 IV drip for pain management. The 

MSO4 IV drip was started at 4:47 p.m. on October 19 and was continued until the 

patient’s death at 6:45 p.m. that same evening. 

 

3

 Sometimes called “clinically severe obesity”; this is defined as being 100 pounds or more over the ideal body 

weight or having a Body Mass Index [BMI] of 40 or higher. 

VA Office of Inspector General 3 
Quality of Care Issues, Clement J. Zablocki VA Medical Center Milwaukee, Wisconsin 

We did not substantiate patient B was denied pain medications and allowed to suffer 

during the last stage of his life on the PCU. 

Patient C Case History and Findings 

Patient C was a 61-year-old male veteran who was diagnosed with lung cancer in April 

2006. He was admitted to the medical center on October 22 with symptoms of nausea, 

vomiting, weight loss, and unsteadiness. Further testing revealed that the lung cancer had 

metastasized (spread) to the patient’s brain. The patient was transferred to the PCU on 

October 24 for end of life care. The patient received radiation treatments for the 

metastatic brain lesions from October 16 to October 30. 

On October 24 the physician ordered MSO4 15 mg by mouth every 3 hours as needed for 

pain. The patient received the first dose on October 27 at 11:06 p.m. and the last dose on 

November 5 at 4:53 a.m. 

On November 3, the patient told the nurse that he was getting weaker; however, he 

denied being in any pain at that time. He expressed a desire to participate in a parade the 

following day. The patient’s family had ambivalent feelings about taking him out of the 

medical center on a pass, but they decided that they would take it minute by minute. 

On November 4 at 3:00 a.m. the patient’s daughter voiced concerns regarding the 

appearance of the patient’s urine. The patient’s urine was very concentrated and dark 

amber in color. The nurse told the daughter that the reason the urine was so dark in color 

was most likely due to the fact that the patient had a decrease in oral intake. The patient 

denied any pain or burning upon urination. The daughter was concerned that the patient 

might have a urinary tract infection and wanted to have her father treated with antibiotics 

before they leave for the parade the next day to avoid further pain. The nurse notified the 

physician on call and relayed the daughter’s concerns. The physician did not feel 

antibiotics were needed at this time and advised that treating the patient’s pain would be 

the foremost thing to do at this point. The daughter was agreeable to this plan, and no 

new orders were given. 

On November 4 at 9:15 a.m., the patient left the medical center with his family to attend 

the parade. The patient and his family returned to the medical center at 11:11 a.m. The 

patient seemed proud of his accomplishment and denied being in any pain at that time. 

His appetite was poor, the nurse noted that he only consumed 10 percent of his lunch, and 

his family stated that he had vomited outside. The patient refused medications offered 

for vomiting. On November 5 at 3:54 a.m., the patient experienced pain and anxiety and 

was given pain medication as ordered. At 4:45 a.m. the physician was notified that the 

medication only provided short term relief, and the patient’s nonverbal pain was now 

VA Office of Inspector General 4 
Quality of Care Issues, Clement J. Zablocki VA Medical Center Milwaukee, Wisconsin 

assessed at 10 on the pain scale.4 At 4:53 a.m. the patient was given MSO4 4 mg by 

intramuscular injection for pain. He died at 5:14 a.m. 

We did not substantiate that patient C was denied pain medications and allowed to suffer 

during the last stage of his life on the PCU. While we substantiated that the patient’s 

daughter expressed concerns regarding the patient possibly having a urinary tract 

infection, the daughter agreed to the physician’s recommended treatment plan of care. 

Patient D Case History and Findings 

Patient D was a 75-year-old male veteran admitted to the medical center on October 26, 

2006, for an open lung biopsy for interstitial lung disease.5

 The patient developed 

pneumonia and other respiratory complications and was transferred to the ICU. The 

biopsy identified a type of pulmonary fibrosis with poor response to treatment. The 

patient’s family considered caring for him at home; but after discussions with staff, they 

chose palliative care with do not resuscitate, intubate or re-hospitalize orders. The patient 

was admitted to the PCU by the clinician on October 26. Documentation shows that the 

patient was alert and mildly dyspneic (short of breath) with no pain. The patient was 

aware that his lung condition was terminal. The clinician documented a family 

discussion about his terminal condition and that his life expectancy was predicted as days 

to weeks. The patient told the clinician he was hesitant about taking MSO4 for pain as it 

made him “hazy.” The clinician informed the patient and family that the medication 

would be available as needed. 

During the night of November 6, the patient removed his ambient oxygen supply, and his 

pulse oximetry level (an indirect, noninvasive assessment of oxygen in the blood) 

dropped to 54 percent (normal 95–100 percent). The response team was notified and 

after administering MSO4 the patient was able to relax and sleep. The patient’s pulse 

oxygen leveled off at 76 percent. On November 7, the patient was alert with a good 

appetite and stated that he “felt great.” However, the patient quickly became fatigued, 

with his pulse oxygen levels fluctuating in the 70s and 80s. The patient was alert and 

denied any discomfort. The daughter was at his bedside, and the clinician discussed the 

patient’s deteriorating status with her. 

On November 7 at 10:57 a.m., the clinician told the family that the patient would soon 

require a MSO4 drip and or other medications to help him relax and breathe easier. At 

11:41 a.m. the clinician suggested to the family that the patient be started on a MSO4 IV 

drip. The family agreed with this plan. The patient continued to get MSO4 IV push 

(injected into the line going directly into the vein and blood stream) as needed, while 

waiting for the MSO4 IV drip to be started. The MSO4 IV drip was ordered at 1:09 p.m. 

 

4

 Pain is assessed using the 0–10 numerical rating scale, with 10 being the worst. 

5

 A group of inflammatory and scarring processes that affect the gas exchanging area of the lungs. 

VA Office of Inspector General 5 
Quality of Care Issues, Clement J. Zablocki VA Medical Center Milwaukee, Wisconsin 

While the IV team was attempting to obtain IV access in another site for the MSO4 drip, 

the patient relaxed, became somnolent, and suddenly stopped breathing. He was 

pronounced dead at 2:15 p.m. The MSO4 IV drip was never started. 

We did not substantiate that patient D’s son had to scream and beg the clinician to 

administer MSO4 for the patient’s comfort. Documentation shows that the clinician 

involved the patient’s family in treatment decisions including decisions regarding pain 

management immediately prior to the patient’s death. There are no documented 

conversations with the patient’s son, and the clinician could not recall any personal 

communication with the son. 

We substantiated that the MSO4 IV drip arrived on the PCU after the patient’s death. 

However, the patient received MSO4 IV push for pain as needed prior to his death. 

Patient E Case History and Findings 

Patient E was an 81-year-old male veteran admitted to an acute care unit at the medical 

center on September 16, 2006, with diagnoses of progressive dyspnea, chronic 

obstructive pulmonary disease, congestive heart failure, chronic lymphocytic leukemia, 

and a 40-pound weight loss. He was transferred to the PCU for end of life care. 

Admission medication orders included a daily oral dose of 20 mEqs (milliequivilents) of 

potassium chloride. On September 27, a nurse, who was assigned to care for the patient 

that day, administered an additional oral dose of 40 mEq potassium chloride to the 

patient. The nurse told us that the patient’s potassium level was at a low normal that day, 

and when she saw a potassium chloride tablet with the patient’s name on it arrive on the 

unit, she assumed it was for him. However, there were two patients on the unit that day 

with the same last name. Later, when another nurse asked if the potassium chloride that 

had been ordered for her patient had arrived, the nurse in question realized she had given 

another patient’s medication to Patient E. 

The nurse did not use the medical center’s Bar Code Medication Administration (BCMA) 

system machine, which is required by policy. The BCMA system is designed to reduce 

the chance of medication error through a verification process that ensures that the right 

patient gets the right medication at the right time by the right route, and of the right dose. 

To start the verification process, the BCMA system requires staff to scan the barcode on 

the patient’s armband before administering any medication. Use of the BCMA system 

might have prevented this error. 

When the nurse became aware of the medication error, she immediately notified the 

clinician. She also informed the patient of the error and told him he would be monitored. 

The clinician examined the patient, reviewed his recent laboratory values, and ordered 

repeat laboratory testing for the following morning. The clinician told us that since the 

VA Office of Inspector General 6 
Quality of Care Issues, Clement J. Zablocki VA Medical Center Milwaukee, Wisconsin 

patient’s potassium level was at low normal, she did not feel the urgency to repeat it any 

earlier. The laboratory results the following day remained within normal range. 

The nurse appropriately informed the patient, initiated an incident report, and submitted 

the report to her immediate supervisor. However, she did not document this extra dose in 

the patient’s medical record. The nurse made an addendum to the medical record to 

document the extra dose during our site visit. 

At the time of the medication error, managers took immediate action, and the nurse was 

counseled regarding medication administration procedures and the use of the BCMA 

system for all medication administration. 

We substantiated that patient E was given an extra dose of medication that was not 

ordered. However, the medication was given by a nurse not the clinician. There was no 

documentation in the patient’s medical record that the clinician informed the patient’s 

family of the medication error, and the clinician did not recall discussing this incident 

with them, as required by Veterans Health Administration (VHA) Handbook 1050.1. 6

We did not substantiate that the medication error caused the patient’s premature death. 

The patient died 13 days after the error, and laboratory results indicated the patient’s 

potassium level was within normal limits at that time. 

Palliative Care Unit Inspection: 

We inspected the PCU on May 2 and found the unit to be clean and appropriately 

maintained. However, we identified two concerns that required management’s 

immediate attention. 

The unit nurse manager’s office door was open, and a set of keys was lying on the table. 

Sensitive patient documents were on the desk and the computer terminal was open with 

sensitive information on the screen. Staff was unaware of the office being open during 

our inspection of the unit. Since the unit manager was unavailable, we requested that the 

office door be immediately locked to safeguard the keys and sensitive information. 

We observed that the housekeeper’s storage room door was open, and the housekeeper 

was not in the immediate area. Because hazardous cleaning products are stored in this 

room that may be harmful to patients, we requested that the door be immediately closed 

and locked. 

 

6

 VHA Handbook 1050.1, VHA National Patient Safety Improvement Handbook, issued 01/30/2002. 

VA Office of Inspector General 7 
Quality of Care Issues, Clement J. Zablocki VA Medical Center Milwaukee, Wisconsin 

Recommendations

Recommendation 1. The VISN Director should ensure the Medical Center 

Director takes action to require all PCU staff to use the BCMA system when 

administering medications and all clinical disclosures are documented according to VHA 

Handbook 1050.1 and medical center policy. 

Recommendation 2. The VISN Director should ensure that the Medical Center 

Director takes action to ensure all PCU staff comply with patient confidentiality and 

computer security policies. 

Recommendation 3. The VISN Director should ensure that the Medical Center 

Director takes action to ensure PCU staff comply with medical center policy and Joint 

Commission’s Environment of Care Standards for storing hazardous cleaning products. 

Comments: 

The VISN and Medical Center Directors agreed with the findings and recommendations 

and provided acceptable improvement plans. (See Appendixes A and B, page 10–13 for 

the full text of their 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 8 
Quality of Care Issues, Clement J. Zablocki VA Medical Center Milwaukee, Wisconsin 

Appendix A 

VISN Director Comments 

Department of 

Veterans Affairs Memorandum

Date: August 7, 2007 

From: VISN Director (10N12) 

Subject: Healthcare Inspections: Quality of Care Issues, Clement 

J. Zablocki VA Medical Center Milwaukee, Wisconsin

To: Director, Chicago Regional Office of HC Inspections 

Attached please find responses from Milwaukee VAMC to all 

recommendations. I have reviewed and concurred with the 

responses and action plans. Thank you. 

James W. Roseborough, FACHE 

VA Office of Inspector General 9 
Quality of Care Issues, Clement J. Zablocki VA Medical Center Milwaukee, Wisconsin

Appendix B 

Medical Center Director Comments 

Department of 

Veterans Affairs Memorandum

Date: August 6, 2007 

From: Acting Medical Center Director (695/00) 

Subject: Healthcare Inspections: Quality of Care Issues, Clement 

J. Zablocki VA Medical Center Milwaukee, Wisconsin 

To: Verena Briley-Hudson, Director, Chicago Regional Office of 

Healthcare Inspection, Office of Inspector General 

I have reviewed the draft report and concur with the 

recommendations. The potential patient safety issues noted in 

the draft report merit our attention. Thank you for the 

opportunity to review the draft report and provide the 

improvement that is needed. 

Attached are the actions we plan to take in order to improve 

the quality of care we provide to those we serve. 

If you have any questions please contact Jodi J. Johnson, 

Manager, PI (PI/695) at (414) 384-2000 ext. 42517. 

(original signed by:)

Larry L. Berkeley 

VA Office of Inspector General 10 
Quality of Care Issues, Clement J. Zablocki VA Medical Center Milwaukee, Wisconsin

Medical Center Director’s Comments 

to Office of Inspector General’s Report 

The following Director’s comments are submitted in response 

to the recommendation(s) in the Office of Inspector General’s 

Report: 

OIG Recommendation(s)

Recommendation 1. The VISN Director should ensure the Medical Center Director 

takes action to require all PCU staff to use the BCMA system when administering 

medications and all clinical disclosures are documented according to VHA 

Handbook 1050.1 and medical center policy. 

Concur Target Completion Date: 9/30/07 

The Medical Center has been fostering a culture of patient safety related to medication 

administration and disclosure and as such has previously taken actions to promote 

understanding and compliance with these vital efforts. 

(a) We have concluded that the finding in May 2007 related to by-passing of the Bar 

Code Medication Administration (BCMA) system was related to individual 

compliance and perception of the nurse on the PCU. The nurse involved in the 

medication event on PCU was counseled by her supervisor and appropriate action 

was taken. The Clement J. Zablocki VA Medical Center (ZVAMC) will monitor all 

medication events on the PCU for proper use of BCMA during Quarter 4, 2007. Each 

event related to BCMA will be aggregated and reviewed for common themes (shift, 

nurse, medication type, etc) so that unit-specific follow up (re-education, etc) can be 

provided. 

(b) ZVAMC has a medical center disclosure policy that follows VHA Handbook 1050.1. 

At the time of the May 2007 OIG review educational activities related to disclosure 

continued to take place. All PCU staff have been notified of the local policy with 

regard to disclosure. Performance Improvement/ Risk Management will conduct a 

concurrent review of any adverse events in PCU for evidence of disclosure and 

provide real-time feedback in order to meet the intent of the Handbook. 

VA Office of Inspector General 11 
Quality of Care Issues, Clement J. Zablocki VA Medical Center Milwaukee, Wisconsin

Recommendation 2. The VISN Director should ensure that the Medical Center 

Director takes action to ensure all PCU staff comply with patient confidentiality and 

computer security policies. 

Concur Target Completion Date: 9/30/07 

The Medical Center has taken the following immediate actions to correct this finding: 

Follow up training for PCU staff was provided locally regarding information security of patient 

records (bedside clip boards and computer work stations). The Associate Director for Patient/ 

Nursing Services led a review to ensure that sensitive data was removed from non-secured areas. 

The Program Manager involved with this finding in May 2007 has been counseled and 

appropriate action has been taken. Ongoing monitoring will continue via PI driven facility tracers 

and Environment of Care Rounds. Findings will be shared with leadership and medical center 

councils and immediate corrective actions will be taken as needed. Due to the amount of 

information that is used in healthcare, ZVAMC will continue to monitor the security of 

information on an ongoing basis.

Recommendation 3. The VISN Director should ensure that the Medical Center 

Director takes action to ensure PCU staff complies with medical center policy and 

Joint Commission’s Environment of Care Standards for storing hazardous cleaning 

products. 

Concur Target Completion Date: 9/30/07 

The housekeeper working in the PCU received immediate education related to specific 

chemicals stored in housekeeping closets and the rationale for securing them. This 

training will be added to annual housekeeper competency review for FY 2008. 

VA Office of Inspector General 12 
Quality of Care Issues, Clement J. Zablocki VA Medical Center Milwaukee, Wisconsin

Appendix C 

OIG Contact and Staff Acknowledgments 

OIG Contact Verena Briley-Hudson, MN, RN, Director 

Chicago Office of Healthcare Inspections 

(708) 202-2672 

Acknowledgments Wachita Haywood, RN, Associate Director 

Michael Shepherd, MD, Medical Consultant 

Judy Brown, Program Support Assistant 

VA Office of Inspector General 13 
Quality of Care Issues, Clement J. Zablocki VA Medical Center Milwaukee, Wisconsin

Appendix D 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, Veterans Integrated Service Network 12 (10N12) 

Director, Clement J. Zablocki VA Medical Center (695/00) 

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: Russell D. Feingold and Herb Kohl 

U.S. House of Representatives: Steve Kagan, Gwen Moore, Thomas Petri, and Paul Ryan 

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

VA Office of Inspector General 14