Department of Veterans Affairs 

Office of Inspector General 

Healthcare Inspection 

Community Residential Care 

Program Review 

VA Maryland Health Care System 

Baltimore, Maryland 

Report No. 06-02265-106 March 23, 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 
Community Residential Care Program Review, VA Maryland Health Care System, Baltimore, MD

VA Office of Inspector General 

Contents 

Page 

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

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

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

Scope and Methodology............................................................................................... 2

Findings and Conclusions ..................................................................................3 

Issue 1: Alleged Patient Abuse....................................................................................... 3

Issue 2: Alleged Residence of Patients in Unlicensed or Unapproved Homes.... ......... 4

Issue 3: Alleged Financial Exploitation of Patients by CRC Home Sponsors ............... 4

Issue 4: Alleged Lack of a Delegating Nurse ................................................................. 6

Issue 5: Alleged Mismanagement of CRC Homes......................................................... 6

Issue 6: Alleged Poor Communication Among Staff .................................................... 8

Comments......................................................................................................................... 9

Appendixes

A. VISN Director Comments ...................................................................................... 10

B. Health Care System Director Comments ............................................................... 11

C. OIG Contact and Staff Acknowledgments............................................................. 16

D. Report Distribution................................................................................................. 17
Community Residential Care Program Review, VA Maryland Health Care System, Baltimore, MD

Executive Summary 

The purpose of this inspection was to determine the validity of multiple allegations 

pertaining to patients in the VA Maryland Healthcare System (the system), Community 

Residential Care (CRC) program. These allegations included alleged abuse of patients; 

financial exploitation of patients; placing patients in unlicensed or unapproved homes; 

mismanagement of the CRC homes; and poor communication among VA CRC program 

staff, Mental Health Intensive Case Management (MHICM) program staff, and other 

system staff. 

Although we substantiated that a patient was fed food that was past its “use-by” date, we 

concluded the patient was not harmed. Furthermore, we found no other outdated food 

during our review. We found that all patients in the CRC program reside in State 

licensed homes. There are patients in the MHICM program who do not reside in State 

licensed CRC-approved homes, but there are valid reasons. In addition, veterans are 

made aware of the home’s status prior to placement and sign a waiver indicating they 

know about the unapproved status of the home. With regard to financial exploitation, we 

found that there were instances of facility operators/sponsors taking loans from veterans. 

Appropriate corrective actions were taken by the VA CRC staff. However, the CRC staff 

needs to review, approve, and document financial transactions and arrangements between 

sponsors and patients. At the time of our review, all CRC homes had a Delegating Nurse 

(a nurse to supervise unlicensed CRC home staff who pass medications to patients). 

CRC sponsors had completed background checks on all staff as required, and State home 

inspections were current. However, we substantiated that not all CRC homes were 

visited monthly by CRC staff and that documentation of appropriateness for continuing in 

the CRC program and annual physical exams were not always documented. Furthermore, 

there were inter-departmental communication problems and documentation deficiencies. 

We made recommendations that: 

• VA CRC staff review, approve, and document all financial transactions and 

arrangements between sponsors and patients. 

• Monthly visits to patients are conducted and documented. 

• Annual physicals are performed and appropriateness for continued stay in CRC 

homes is documented. 

• VA CRC and MHICM staff meet regularly and document pertinent issues. 

System management agreed with our findings and recommendations and submitted 

acceptable implementation plans. We will follow up on the planned actions until they are 

completed. 

VA Office of Inspector General i 
DEPARTMENT OF VETERANS AFFAIRS

Office of Inspector General 

Washington, DC 20420 

TO: Director, Veterans Integrated Service Network 5 (10N5) 

SUBJECT: Healthcare Inspection - Community Residential Care Program Review 

VA Maryland Health Care System, Baltimore, MD 

Purpose 

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

multiple allegations pertaining to patient care issues in the VA Maryland Healthcare 

System (the system) Community Residential Care (CRC) program. These allegations 

included alleged abuse of patients; financial exploitation of patients and mismanagement 

of patients’ funds by CRC facility operators/sponsors;1

 placement of patients in 

unlicensed or unapproved CRC homes; mismanagement of CRC homes; and poor 

communication among members of the VA CRC staff, Mental Health Intensive Case 

Management (MHICM) staff, and other system staff. The purpose of this inspection was 

to evaluate the validity of the allegations. 

Background 

The system offers a full range of inpatient, outpatient, and primary care services. The 

system consists of three divisions: the Baltimore medical center and campuses at Perry 

Point and Loch Raven. The system operates 727 authorized beds. The Perry Point 

Campus offers long term inpatient, outpatient mental health, and domiciliary care for 

patients; it is also the site of the system’s CRC program management. The CRC Program 

consists of 50 homes. 

Since 1951, the VA CRC program has provided health care supervision to eligible 

patients not in need of acute hospital care, but who, because of medical and/or 

psychosocial health conditions, are not able to live independently and have no suitable 

family or significant others to provide the needed supervision and supportive care. The 

CRC program is an important component in the VA’s continuum of long term care. 

 

1

 “Facility Operator (Sponsor). A facility operator assumes the management responsibility for the facility and may 

or may not be the provider. NOTE: Historically, the facility operator has been called the sponsor.” VHA 

Handbook 1140.1, Community Residential Care Program, March 7, 2005. 

VA Office of Inspector General 1 
Community Residential Care Program Review, VA Maryland Health Care System, Baltimore, MD 

services. Before patients are placed in CRC homes, the home must first meet state 

licensing requirements and then pass an extensive VA inspection. Patients are placed in 

CRC homes by VA CRC social workers and case managers. Placement is made in 

residential settings inspected and approved by the VA but chosen by the patient. On 

May 23, 2006, we received complaints of multiple deficiencies in the system’s CRC 

program. 

The themes of the allegations centered on mismanagement of the CRC program by VA 

staff. They may be categorized as follows: 

• Patient Abuse. It was alleged that an elderly female patient was given expired food 

and did not have her diapers changed for 4 days. 

• Patients Reside in Unlicensed or Unapproved Homes. It was alleged that the MHICM 

team was sending patients to unapproved homes, CRC sponsors inappropriately 

moved patients between approved and unapproved homes, and patients (not enrolled 

in the CRC program) reside in CRC homes without the knowledge of VA CRC staff. 

• Financial Exploitation of Patients by CRC Sponsors. It was alleged that patients work 

in CRC homes without compensation or for cigarettes, and that CRC sponsors borrow 

patients’ funds. 

• Lack of a Delegating Nurse.

2

 It was alleged that not all CRC homes have a 

delegating nurse. 

• Mismanagement of CRC Homes. It was alleged that VA CRC staff failed to make 

required monthly visits to CRC homes. It was also alleged that CRC homes failed to 

complete required background checks for all employees, did not have current State 

inspections, and did not report adverse events to appropriate VA CRC staff. It was 

further alleged that there are more patients living in one of the CRC homes than the 

home is licensed for, that patients at CRC homes do not receive annual physicals, and 

that CRC staff do not receive appropriate required annual training. 

• Poor Communication. It was alleged that there was poor communication among 

members of the VA CRC staff, MHICM staff, and other system staff. 

Scope and Methodology 

On July 10–14, 2006, we conducted a site visit at the Perry Point campus to review the 

CRC program. Prior to our visit, we conducted a telephone interview with the 

complainant in order to clarify the initial written allegations received by the OIG. We 

interviewed the complainant, the CRC Director, the Director of the Geriatric and 

Extended Long Term Care Service, who is also the medical director for the CRC 

 

2

 In Maryland, a nurse may delegate the responsibility to perform specific nursing tasks to an unlicensed individual 

who meets certain criteria. The administration of medications is one of these tasks. The delegating nurse is required 

to visit the CRC home every 45 days to oversee the administration of medications. 

VA Office of Inspector General 2 
Community Residential Care Program Review, VA Maryland Health Care System, Baltimore, MD 

program, and clinicians involved in the care of the patients referred to in the 

complainant’s allegations. We reviewed available medical records, pertinent medical 

center policies and procedures, and other documents relevant to the case. We also visited 

15 CRC homes, where we reviewed documentation pertinent to the care of patients and 

interviewed sponsors of the homes and patients residing in these homes. 

The inspection was performed in accordance with the Quality Standards for Inspections

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

Findings and Conclusions 

Issue 1: Alleged Patient Abuse 

This allegation was not substantiated. 

The complainant alleged that an elderly female patient was fed food with expired “use 

by” dates (obtained from a local food bank), stayed in soiled diapers for 4 days, and the 

VA Home Based Primary Care (HBPC) staff did not provide proper care for the patient. 

The HBPC staff provides VA nursing care in the community and in CRC homes. The 

83-year-old patient, who has resided at various times in two different CRC homes owned 

by the same sponsor, has a medical history that includes depression, gastroesophegeal 

reflux disease, hypertension, chronic back pain, osteoporosis, and chronic diarrhea. On 

January 26, 2006, the patient was referred to the HBPC program by a VA CRC social 

worker for “multiple medical problems and homebound” status. 

On February 3, a HBPC nurse practitioner completed the initial Evaluation/Treatment 

Plan for the patient. After this initial assessment, the nurse practitioner reported concerns 

about outdated Isomil (liquid feeding) the patient had received and an ulcer on the 

patient’s heel to a VA CRC social worker. 

We reviewed all electronic clinical note entries between February 3 and May 12. The 

patient was seen by Vascular Surgery clinicians for evaluation of the heel ulcer on 

March 6, and it was noted to be almost completely healed and less than 1 centimeter in 

diameter. On May 3, VA CRC staff described the heel ulcer as a small red pressure area. 

The CRC staff also documented that the patient complained that the CRC sponsor refused 

to change her diaper. HBPC staff documented on several occasions that the patient was 

clean and dry. We did not find any other documentation indicating improper delay in 

changing the patient’s diapers or that the patient was kept in soiled diapers for an 

inappropriate length of time. 

In late May, the patient moved to a new unapproved CRC home that was managed by a 

former employee of the home from which she had moved. This move was approved by 

the patient’s daughter, who had legal authority to make health care decisions for the 

VA Office of Inspector General 3 
Community Residential Care Program Review, VA Maryland Health Care System, Baltimore, MD 

patient and was aware of the unapproved status of the new home. At the time of our 

inspection, the home sponsor had applied for State licensure and had requested VA CRC 

approval. The patient continues to be followed by HBPC at this home. 

We visited 15 additional CRC homes and checked expiration dates on samples of the 

food served to the patients. No outdated food was discovered. We made no 

recommendations. 

Issue 2: Alleged Residence of Patients in Unlicensed or Unapproved Homes 

We substantiated this allegation. However, patients enrolled in the MHICM program are 

able to be placed in unapproved homes under certain specific circumstances. 

The complainant alleged that patients were placed in unapproved homes by MHICM and 

system personnel not involved in the CRC program, and that patients were placed in 

homes not licensed by the State. We found that all patients enrolled in the CRC program 

reside in State licensed homes. However, patients enrolled in the MHICM program may 

reside in homes not licensed by the State. The system Mental Health Care Service and 

the MICHM teams are both authorized by the VA and mandated by the North East 

Program Evaluation Center (NEPEC) to facilitate the community placement of patients 

with a history of frequent psychiatric admissions. NEPEC is responsible for designing, 

implementing, and evaluating innovative mental health programs that have facilitated the 

transformation of the VA mental health care system from a traditional, hospital based 

system, to an information-driven community based system. NEPEC requires that 

MHICM patients are placed in the least restrictive environment possible in order to foster 

mental health recovery. MHICM staff are authorized to place patients in unapproved 

housing when placement within a CRC approved home is not appropriate or possible 

(such as too expensive, too restrictive, no other vacancies available, or the patient 

refused). In such circumstances, the patient signs a “waiver” acknowledging that the 

patient is aware of the unapproved status of the home. 

In April 2006, a patient was admitted into the MHICM program and placed in an 

unapproved home after he signed a waiver agreeing with the placement. We also found 

that several other MHICM patients reside in homes that are State licensed but not VAapproved CRC homes; they also signed waivers agreeing with the placement. We made 

no recommendations. 

Issue 3: Alleged Financial Exploitation of Patients by CRC Home Sponsors 

We substantiated this allegation. 

Patients must be allowed to manage their own personal financial affairs except when 

restricted in this right by law or by the plan of needed care. If the patient requests 

assistance in managing personal financial affairs, the request must be documented in the 

electronic medical record and evaluated by the CRC program coordinator and other 

VA Office of Inspector General 4 
Community Residential Care Program Review, VA Maryland Health Care System, Baltimore, MD 

clinicians as appropriate. When a CRC home gets approved by the VA, the sponsor is 

provided with a CRC handbook and signs a contract with the VA, which includes a 

provision prohibiting the borrowing of funds from patients under any circumstances. 

On January 30, 2006, a VA CRC staff member was notified that a patient loaned $600 to 

his CRC sponsor, who reportedly repaid $200 leaving a balance of $400. On February 6, 

the CRC program coordinator was notified of the situation; on February 7, a CRC social 

worker discussed the incident with the sponsor, confirming the existence of a loan. The 

CRC social worker requested that the balanced owed to the patient be paid within 

3 weeks, and instructed the sponsor not to borrow any additional funds at any time, in 

accordance with the VA contract. The social worker interviewed the four additional 

patients living at that home; they denied loaning any funds to the sponsor. This home 

was subsequently removed from the CRC program by the system director. 

When the home was removed from the CRC program, three of the patients were relocated 

to another CRC home on March 20. The patient who had originally loaned his sponsor 

$600 was admitted to the system’s Long Term Care Geriatrics Medical Unit for followup regarding a chronic medical condition. The $400 owed to this patient was paid in full. 

On April 6, two of the four patients who had been interviewed previously admitted that 

they had loaned $1,500 to the sponsor of the home and $60 to the sponsor’s friend. The 

social worker hand delivered a letter to the sponsor of the home demanding repayment of 

these loans. The sponsor signed a statement admitting that she had borrowed these 

additional funds and agreed to repay them. 

The social worker contacted the two patients on May 15, and they stated that the funds 

had not been repaid. The social worker contacted the Maryland Office of the Attorney 

General and was instructed to contact the local police, which she did. The police went to 

the sponsor’s home and requested that she repay the funds. The sponsor signed a 

statement stating that she would repay these funds. The social worker informed the 

patients’ family members of the VA action taken and notified them of possible avenues 

of redress. To date, these two patients have not been repaid. 

The VA CRC staff sent letters to all CRC sponsors in the program reminding them of the 

prohibition against borrowing money from patients; citing the Code of Maryland 

Regulations, VA CRC Handbook, and the CRC contract; and stating that failure to abide 

by this contract would result in termination of the contract and the removal of patients 

from sponsor’s homes. 

VHA guidelines require documentation in the electronic medical record of all financial 

arrangements made with the patients or their representatives. Financial arrangements 

may include, but are not limited to, money for vacation, clothes, and arrangements made 

to hold a patient’s room at the home if the patient is hospitalized. We reviewed the 

VA Office of Inspector General 5 
Community Residential Care Program Review, VA Maryland Health Care System, Baltimore, MD 

medical records of 50 patients and found documentation of financial arrangements in 

22 cases (44 percent). 

Recommendation 1. We recommend that the VISN Director ensure that the 

System Director requires the CRC Program Coordinator to: (a) review, approve, and 

document all financial transactions and arrangements between sponsors and patients; 

(b) take administrative action against sponsors who take loans from patients; (c) with the 

advice of Regional Counsel, notify, in writing, all patients still owed money of their legal 

options to recover their monies; and (d) monitor the cases until all monies are recovered. 

Issue 4: Alleged Lack of a Delegating Nurse 

We substantiated this allegation but found that managers had taken appropriate actions. 

In Maryland, a nurse may delegate the responsibility to perform a nursing task to an 

unlicensed individual who has taken a required medication administration course or a 

certified nursing assistant, provided the task is within the area of responsibility of the 

nurse delegating the act. The administration of medications is one of these tasks. The 

delegating nurse is required to visit the CRC home every 45 days to review patient 

medication records and to compare this record with physician orders. All CRC sponsors 

and staff giving medications must be certified by the State every 2 years. Certified 

individuals are listed on the Maryland State Nursing Web page. CRC homes that do not 

have a delegating nurse are reported to the Maryland Office of Health Care Quality, 

which may revoke the CRC home license or implement a plan of correction. 

One of the approved CRC homes did not have a delegating nurse for 4 months when their 

delegating nurse moved out of the area. The CRC Program Coordinator worked with the 

home and a delegating nurse was found to perform the task. At the time of our review, 

all 50 licensed CRC homes that house patients and are followed by the VA CRC and 

MHICM programs had delegating nurses. We made no recommendations. 

Issue 5: Alleged Mismanagement of CRC Homes 

We substantiated some of the complainant’s allegations concerning mismanagement. 

Monthly Visits. VHA guidelines require that each patient receive a visit from the VA 

CRC program staff at least monthly. The purpose of the visit is to make sure the patient 

is adjusting to the home and to address any questions or problems that the sponsor or 

patient may have. We reviewed the medical records of 50 patients participating in the 

CRC program. Over the past 2 years, 21 of the 50 patients (42 percent) in the CRC 

program were visited on a monthly basis. 

Annual Physicals. Each year patients in CRC homes are required to have a physical 

examination and determination of the appropriateness of continued CRC placement 

documented in their medical record. In our sample of 50 patient medical records, from 

VA Office of Inspector General 6 
Community Residential Care Program Review, VA Maryland Health Care System, Baltimore, MD 

fiscal year 2005 documentation we found 5 records (10 percent) that had no 

documentation of an annual physical, and 44 records (88 percent) that had no 

documentation regarding the patient’s appropriateness for continuing in the CRC 

program. 

Background Checks. The complainant alleged that CRC sponsors failed to conduct 

background checks and that patients were placed in a home managed by a convicted 

felon. CRC homes are required to submit background checks for caregivers employed at 

the homes to both the state and system inspection teams. Background checks are 

required of the sponsor and any person who is employed or provides care. Family 

members such as spouses, adult children, and significant others are not required to have 

background checks if they are not providing care to the patients. 

At the time of the original allegation, not all CRC home employees had completed 

background checks. At the time of our inspection, however, all background checks were 

current. The system needs to have a process to verify that background checks are current. 

The sponsor of a State licensed and VA approved CRC home in the city of Baltimore is a 

felon convicted many years ago. The sponsor submitted his background check, including 

his criminal record, to the State licensing board and to system employees. The 

information, along with other information concerning the sponsor’s positive community 

activities, was considered by the CRC Program Coordinator in making the decision to 

approve the home. There is one patient enrolled in the MHICM program who has resided 

in this home since March 1, 2005. The patient reported that he is satisfied with his living 

arrangements and denied any concerns or complaints regarding the owner of the home. 

State Inspections Incomplete. The complainant also alleged that State inspections were 

not completed at several CRC homes. We contacted the State licensing board and were 

told that the inspection schedule is backlogged. At the time of our inspection, all VA 

approved CRC homes had current inspections. 

Patients Working in CRC Homes. It was alleged that CRC homes require patients to 

work but were not providing fair compensation. Under current CRC guidelines, patients 

will not perform household duties, other than personal housekeeping tasks, unless they 

receive compensation for these duties, or are told in advance that the duties are voluntary 

and they agree to perform the duties without compensation. We found one patient 

residing at a CRC home who performed “odd jobs” for the sponsor. However, the 

sponsor paid the patient and also withheld appropriate state and Federal taxes. 

Overcrowding. Each CRC home is licensed to house up to a maximum number of 

patients in the home. If a home wishes to exceed the maximum limit, it must apply to the 

state for an increase in the number of patients allowed to reside in the home. It was 

alleged that one of the homes had 11 patients and it was only licensed for 10 patients. 

We found that the home did have 11 residents. Ten patients were living in the assisted 

VA Office of Inspector General 7 
Community Residential Care Program Review, VA Maryland Health Care System, Baltimore, MD 

living part of the home. The other resident was a former patient who had graduated from 

the MHICM program and had an apartment that was connected to the assisted living part 

of the home. The 11th resident was living independently and renting the apartment from 

the sponsor. 

We visited 15 of the system’s 50 CRC homes (30 percent) and found they all had current 

State licenses, appeared well managed and clean, and the sponsors were able to provide 

required documentation (such as license and proof of a delegating nurse) upon our 

request. The patients we spoke with knew the VA CRC staff who accompanied us, 

reported satisfaction with their care, and did not voice any complaints. The CRC 

sponsors reported good working relationships with the VA CRC and MHICM staff and 

responsiveness when management problems have arisen with patients. 

Recommendation 2. We recommend that the VISN Director ensure that the 

System Director requires that CRC staff: (a) conduct and document monthly visits to 

patients in the CRC homes, (b) ensure annual physical examinations are performed and 

fitness for continuing stay assessments are documented, and (c) verify that employee 

background checks are current. 

Issue 6: Alleged Poor Communication Among Staff 

We substantiated this allegation. 

The staff we interviewed complained of poor communication between staff members 

within the CRC program itself, between staff in the CRC and MHICM programs, and 

between CRC staff and mental health clinicians. We found that there were no scheduled 

joint meetings between CRC and MCHICM staff. In addition, we did not find 

documentation of discussions of mutual patient concerns between employees in the 

different programs. CRC program staff met regularly to discuss the CRC homes, the 

sponsors, and the patients residing in these homes; but there was no documentation of 

these meetings or of decisions made as a result of these meetings. 

Recommendation 3. We recommend that the VISN Director ensure that the 

System Director requires the CRC program coordinator to: (a) improve medical record 

documentation in accordance with VHA regulations; (b) create an accounting system that 

enables the CRC staff to accurately track CRC monthly visits, CRC home employee 

background checks, training records, and annual CRC home inspections; and (c) conduct 

regular staff meetings and document pertinent issues relevant to the CRC program and 

MHICM program. 

VA Office of Inspector General 8 
Community Residential Care Program Review, VA Maryland Health Care System, Baltimore, MD 

Comments 

The VISN Director and System Director concurred with the findings and 

recommendations and have begun taking actions to implement the recommendations in 

this report. (See Appendix A, pages 10–15 for the complete 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 9 
Community Residential Care Program Review, VA Maryland Health Care System, Baltimore, MD 

Appendix A 

VISN Director Comments 

Department of 

Veterans Affairs Memorandum

Date: December 5, 2006 

From: Network Director, VISN 5 

Subject: Healthcare Inspection - Community Residential Care 

Program Review VA Maryland Health Care System 

To: Director, Management Review and Administrative Service 

(10B5) 

1. This memorandum is in reply to the Community 

Residential Care Program Review, VA Maryland Health 

Care System. 

2. I concur with the corrective actions submitted in the 

attached memorandum from the VAMHCS Director. 

3. Should you have any question or concerns, please contact 

Dr. Archna Sharma, Quality Management Officer, at 410-

691-1142. 

VA Office of Inspector General 10 
Community Residential Care Program Review, VA Maryland Health Care System, Baltimore, MD 

Appendix B 

Health Care System Director Comments 

Department of 

Veterans Affairs Memorandum

Date: November 27, 2006 

From: Director, VA Maryland Health Care System (BT/00) 

Subject: Healthcare Inspection - Community Residential Care 

Program Review VA Maryland Health Care System 

To: Assistant Inspector General for Healthcare Inspections 54 

1. Thank-you for the opportunity to respond to this draft report, 

which identifies improvement opportunities in the management and 

oversight of VAMHCS Community Residential Care Program. 

2. Thank-you again for your thoughtful and meticulous review of 

the allegations. Your assistance in helping us focus on program 

improvement of our CRC Program is greatly appreciated and 

helpful. Our leadership and dedicated CRC staff look forward to 

continuing the excellent service and commitment to our veterans. 

3. If any additional information is needed, please contact, Betsy 

Bradford, RN, MHA, GLTC, Business Manager, 410-642-2411, 

extension, 6352. 

DENNIS H. SMITH 

Attachment 

MDH/brb: 

VA Office of Inspector General 11 
Community Residential Care Program Review, VA Maryland Health Care System, Baltimore, MD 

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 recommend that the VISN 

Director ensures that the System Director require the CRC 

Program Coordinator to: 

(a) Review, approve, and document all financial transactions 

and arrangements between sponsors and patients. 

Concur Target Completion Date: 12/1/2006 

Corrective Action: CRC Sponsors are educated that they are 

not to request/accept loans from the veterans in their care. 

CRC Social Work will document in their monthly notes, 

under "Financial Transactions", any financial dealings 

between veterans and their sponsors. All requests for funds 

from the veteran will be recorded in CPRS and reviewed, 

approved, and cosigned by the CRC Program Coordinator. 

(b) Take administrative action against sponsors who take 

loans from patients. 

 Concur Target Completion Date: 7/27/2006 

We consider this a recommendation to continue present 

practice as illustrated in the case reviewed by the OIG team. 

As of the date of the review, all letters had been sent and we 

were awaiting action by the courts. All loans were settled as 

of July 27, 2006. We have consistently provided education to 

our patients and CRC sponsors not to engage in the loaning of 

money. Each of the incidents involved a single CRC sponsor 

who has subsequently been removed from the program. 

VA Office of Inspector General 12 
Community Residential Care Program Review, VA Maryland Health Care System, Baltimore, MD 

(c) With the advice of Regional Counsel, notify, in writing, 

all patients still owed money of their legal options to recover 

their monies. 

Concur Target Completion Date: 7/27/2006 

We consider this a recommendation to continue with present 

practice illustrated in the case reviewed with the OIG team. 

(d) monitor the cases until all monies are recovered. 

Concur Target Completion Date: 7/27/2006 

Corrective Action: Each of the three cases were monitored 

until all monies had been repaid in full to the satisfaction of 

the veteran and/or his advocate. 

Recommendation 2. We recommend that the VISN 

Director ensure that the System Director requires that CRC 

staff: 

(a) Conduct and document monthly visits to patients in the 

CRC homes. 

Concur Target Completion Date: 12/15/2006 

Corrective Action: All CRC residents are visited monthly and 

findings are documented by the CRC Social Worker. The 

CRC Coordinator is responsible for monitoring 

documentation and reports to the CRC Oversight Committee 

and the GLTC PI [Geriatric and Long Term Care Process 

Improvement] Sub-Council. 

(b) Ensure annual physical examinations are performed and 

fitness for continuing stay assessments are documented. 

Concur Target Completion Date: 11/20/2006 

VA Office of Inspector General 13 
Community Residential Care Program Review, VA Maryland Health Care System, Baltimore, MD 

Corrective Action: The CRC Social Worker will monitor the 

date of the veteran's annual physical to ensure they are seen 

within the appropriate timeframe. Social Work staff have 

added "verification of fitness for continuing stay and 

appropriate placement in CRC" to their documentation. The 

CRC Coordinator is responsible for monitoring 

documentation and reports quarterly to the CRC Oversight 

Committee and the GLTC PI Sub-Council 

(c) verify that employee background checks are current. 

Concur Target Completion Date: 7/31/2006 

All background checks are verified during scheduled 

inspections. We consider this as a recommendation to 

continue with the practice illustrated in the case reviewed 

with the OIG Team. 

Recommendation 3. We recommend that the VISN 

Director ensures that the System Director requires the CRC 

program coordinator to: 

(a) Improve medical record documentation in accordance 

with VHA regulations. 

 Concur Target Completion Date: 11/1/2006 

Corrective Action: All CRC medical records are peer 

reviewed quarterly. Findings are reported to and reviewed by 

the VAMHCS Social Work Practice Council on a biannual 

basis. All notes are documented in accordance with VHA 

regulations. 

(b) Create an accounting system that enables the CRC staff to 

accurately track CRC monthly visits, CRC home’s employee 

background checks, training records, and annual CRC home 

inspections. 

Concur Target Completion Date: 7/31/2006 

Corrective Action: The tracking system has been modified to 

be more user friendly and is available on the shared drive for 

ease of access by program staff. 

VA Office of Inspector General 14 
Community Residential Care Program Review, VA Maryland Health Care System, Baltimore, MD 

(c) Conduct regular staff meetings and document pertinent 

issues relevant to the CRC and MHICM program. 

Concur Target Completion Date: 11/15/2006 

and 12/15/2006 

Corrective Action: 

1) The CRC Monthly staff meeting now includes a standing 

agenda item specifically addressing CRC and MHICM issues. 

Target Date: November 15, 2006. Complete. 

2) A CRC Oversight Committee was created to include: 

Nursing leadership, Performance Improvement, Engineering, 

CRC Education, CRC Nursing, GLTC Director and Business 

Manager, and Coordinators of the CRC and MHICM

programs. Target Date: December 15, 2006. 

VA Office of Inspector General 15 
Community Residential Care Program Review, VA Maryland Health Care System, Baltimore, MD 

Appendix C 

OIG Contact and Staff Acknowledgments 

OIG Contact Randall Snow, JD, Associate Director, 

Office of Healthcare Inspections, Washington, DC 

202-565-8452 

Acknowledgments Gail Bozzelli 

Donna Giroux 

Nelson Miranda 

Michael, Shepherd, MD 

Carol Torczon 

VA Office of Inspector General 16 
Community Residential Care Program Review, VA Maryland Health Care System, Baltimore, MD

Appendix D 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, Veterans Integrated Service Network 5 

Director, VA Maryland Health Care System 

Non-VA Distribution

House Committee on Veterans’ Affairs 

House Appropriations Subcommittee on Military Construction and Veterans Affairs 

House Committee on Oversight and Government Reform 

Senate Committee on Veterans’ Affairs 

Senate Appropriations Subcommittee on Military Construction and Veterans Affairs 

Senate Committee on Homeland Security and Governmental Affairs 

National Veterans Service Organizations 

Government Accountability Office 

Office of Management and Budget 

U.S. Senate: Barbara A. Mikulski, Benjamin L. Cardin 

U.S. House of Representatives: Elijah E. Cummings 

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

VA Office of Inspector General 17