Department of Veterans Affairs 

Office of Inspector General 

Combined Assessment Program 

Review of the 

Northport VA Medical Center 

Northport, New York 

Report No. 07-00577-171 July 19, 2007

VA Office of Inspector General 

Washington, DC 20420 
Office of Inspector General 

Combined Assessment Program Reviews 

Combined Assessment Program (CAP) reviews are part of the Office of Inspector 

General's (OIG's) efforts to ensure that high-quality health care services are 

provided to our Nation's veterans. CAP reviews combine the knowledge and skills 

of the OIG's Offices of Healthcare Inspections and Investigations to provide 

collaborative assessments of VA medical facilities on a cyclical basis. The 

purposes of CAP reviews are to: 

• Evaluate how well VA facilities are accomplishing their mission of providing 

veterans convenient access to high-quality medical services. 

• Provide fraud and integrity awareness training to increase employee 

understanding of the potential for program fraud and the requirement to refer 

suspected criminal activity to the OIG. 

In addition to this typical coverage, CAP reviews may examine issues or 

allegations referred by VA employees, patients, Members of Congress, or others. 

To Report Suspected Wrongdoing in VA Programs and Operations 

Call the OIG Hotline – (800) 488-8244 
Combined Assessment Program Review of the Northport VA Medical Center, Northport, New York 

Contents 

Page 

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

Introduction ..........................................................................................................1

Facility Profile ................................................................................................................. 1 

Objectives and Scope of the Combined Assessment Program Review........................... 1 

Results of Review.................................................................................................3

Opportunities for Improvement ....................................................................................... 3 

Environment of Care .................................................................................................... 3

Computerized Patient Record System Business Rules ................................................ 4 

Quality Management Program ..................................................................................... 5 

Other Observations .......................................................................................................... 6 

Community Based Outpatient Clinics.......................................................................... 6 

Survey of Healthcare Experiences of Patients ............................................................. 7 

Patient Transportation Services.................................................................................... 8 

Appendixes 

A. VISN Director Comments ........................................................................................ 9 

B. Acting Medical Center Director Comments ............................................................ 10 

C. OIG Contact and Staff Acknowledgments............................................................... 13 

D. Report Distribution .................................................................................................. 14 

VA Office of Inspector General 
Combined Assessment Program Review of the Northport VA Medical Center, Northport, New York 

Executive Summary 

Introduction 

During the week of March 12–15, 2007, the Office of Inspector General (OIG) conducted 

a Combined Assessment Program (CAP) review of the Northport VA Medical Center 

(the medical center), Northport, NY. The purpose of the review was to evaluate selected 

medical center operations, focusing on patient care administration and quality 

management (QM). During the review, we provided fraud and integrity awareness 

training to 85 employees. The medical center is under the jurisdiction of Veterans 

Integrated Service Network (VISN) 3. 

Results of Review 

This CAP review focused on five areas. The medical center complied with selected 

standards in the following areas: 

• Community Based Outpatient Clinics (CBOCs). 

• Survey of Healthcare Experiences of Patients (SHEP). 

We identified three areas that needed additional management attention. To improve 

operations, we made the following recommendations: 

• Improve patient safety on the inpatient psychiatric units by modifying or removing 

looped eye hasps from patient lockers. 

• Review the Computerized Patient Record System (CPRS) business rules at least 

annually to ensure compliance with Veterans Health Administration (VHA) 

regulations. 

• Improve Peer Review Committee reporting requirements and performance 

improvement (PI) reporting processes. 

This report was prepared under the direction of Ms. Katherine Owens, MSN, Director, 

Boston Office of Healthcare Inspections. 

VA Office of Inspector General i 
Combined Assessment Program Review of the Northport VA Medical Center, Northport, New York 

Comments 

The VISN and Acting Medical Center Directors agreed with the CAP review findings 

and provided acceptable improvement plans. (See Appendixes A and B, pages 9–12, for 

the full text of the Directors’ comments.) We will follow up on the planned actions until 

they are completed. 

 (original signed by:) 

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

Assistant Inspector General for 

Healthcare Inspection 

VA Office of Inspector General ii 
Combined Assessment Program Review of the Northport VA Medical Center, Northport, New York 

Introduction 

Facility Profile 

Organization. Located in Northport, NY, the medical center offers inpatient and 

outpatient health care services, and it has three CBOCs located in Plainview, Patchogue, 

and Westhampton, NY. It also provides outpatient mental health services at four satellite 

mental health clinics in Islip, Lindenhurst, Lynbrook, and Riverhead, NY. The medical 

center is part of VISN 3 and serves a veteran population of 200,000 in Nassau and 

Suffolk counties. 

Programs. The medical center provides medical and surgical care, primary care, 

extended care, and inpatient and outpatient mental health services. It also supports 

programs in physical medicine and rehabilitation, neurology, oncology, dentistry, and 

geriatrics. 

Affiliations and Research. The medical center is affiliated with the State University of 

New York at Stony Brook School of Medicine and supports over 100 residents, interns, 

and medical students annually. Additionally, it serves as a training site for nursing, 

physical medicine and rehabilitation, ophthalmology, dentistry, optometry, podiatry, and 

other professional and technical related disciplines. 

Currently, the medical center has 35 active research principal investigators and 

approximately 97 active research protocols. The total research funding for fiscal year 

(FY) 2006 was over $3 million. Major areas of research include cancer, lung disease, 

heart disease, hypertension, prostate disorders, and diabetes.

Resources. The medical center’s budget expenditures for FY 2006 totaled over 

$201 million. For FY 2007, the budget is over $216 million. FY 2006 staffing was 

approximately 1,438 full-time employee equivalents (FTE). FY 2007 staffing is 

1,439 FTE, which includes 94 physician and 384 nursing FTE. 

Workload. In FY 2006, the medical center treated over 35,000 unique patients. The 

medical center had 161 operating hospital beds in FY 2006, with an average daily census 

of 96. In FY 2006, there were 170 operating nursing home beds, with an average daily 

census of 122, and 40 Psychosocial Residential Rehabilitation Treatment Program beds, 

with an average daily census of 31. The outpatient workload for FY 2006 totaled 

292,000 visits. 

Objectives and Scope of the Combined Assessment Program Review 

Objectives. CAP reviews are one element of the OIG’s efforts to ensure that our 

Nation’s veterans receive high quality VA health care. The objectives of the CAP review 

are to: 

VA Office of Inspector General 1 
Combined Assessment Program Review of the Northport VA Medical Center, Northport, New York 

• Conduct recurring evaluations of selected health care facility operations, focusing on 

patient care administration and QM. 

• Provide fraud and integrity awareness training to increase employee understanding of 

the potential for program fraud and the requirement to refer suspected criminal 

activity to the OIG. 

Scope. We reviewed selected activities to evaluate the effectiveness of patient care 

administration and QM. Patient care administration is the process of planning and 

delivering patient care. QM is the process of monitoring the quality of patient care to 

identify and correct harmful and potentially harmful practices and conditions. 

In performing the review, we inspected work areas; interviewed managers and 

employees; and reviewed clinical and administrative records. The review covered the 

following activities: 

CBOCs 

CPRS Business Rules 

Environment of Care (EOC) 

QM Program 

SHEP 

The review covered facility operations for FY 2006 and FY 2007 (through 

December 31, 2006) and was done in accordance with OIG standard operating 

procedures for CAP reviews. We followed up on the healthcare suggestions regarding 

patient transportation services from the prior CAP review of the medical center 

(Combined Assessment Program Review of the Northport VA Medical Center, Northport, 

New York, Report No. 04-00403-128, April 14, 2004). We found that managers 

implemented suggested improvement actions and sustained improvement over time. 

We also followed up on recommendations from a report by VHA’s OMI (Final Report: 

Site Visit, Northport Veterans Affairs Medical Center, Northport, NY, February 1, 2007). 

In that report, the OMI made recommendations to improve the medical center’s peer 

review processes. We reviewed the documentation of the follow-up from the medical 

center and found management’s implementation of the OMI recommendations 

acceptable. We consider the OMI recommendations closed. 

During the review, we presented three fraud and integrity awareness briefings for medical 

center employees. These briefings, attended by 85 employees, covered procedures for 

reporting suspected criminal activity to the OIG and included case-specific examples 

illustrating procurement fraud, false claims, conflicts of interest, and bribery. 

In this report, we summarize selected focused inspections and make recommendations for 

improvement. Recommendations pertain to issues that are significant enough to be 

monitored by the OIG until facility managers implement corrective actions. Activities in 

the “Other Observations” section of this report have no reportable conditions. 

VA Office of Inspector General 2 
Combined Assessment Program Review of the Northport VA Medical Center, Northport, New York 

Results of Review 

Opportunities for Improvement 

Environment of Care 

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

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

Occupational Safety and Health Administration, and Joint Commission1

 standards. To 

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

and general maintenance. 

We inspected the following patient care areas: 

Intensive Care Unit Acute Psychiatry Units 21 and 22 

Medical Surgical Unit 23 Medical Unit 33 

Medical Telemetry Unit 34 Nursing Home Care Units (NHCUs) 1–4 

In addition, we interviewed infection control personnel and reviewed infection control 

policies, the infection control annual report, and employee illness and injury data. We 

also reviewed water quality data and the management of patients with multi-drug 

resistant organisms. 

The nurse managers on the units expressed satisfaction with the housekeeping staff 

assigned to their units. The areas inspected were generally clean and well maintained. 

Managers immediately corrected housekeeping issues that we identified, such as 

excessive dust on high surfaces in NHCU 1. 

Water quality data were current, and infection control policies and procedures for 

managing patients with multi-drug resistant organisms were satisfactory. We followed 

up on suggested improvement items from the prior CAP report, such as unsecured 

prescription pads and unclean refrigerators. Managers had implemented the suggested 

action items and sustained improvements over time. 

Condition Needing Improvement. Managers needed to improve patient safety on the 

inpatient psychiatry units by modifying or removing looped eye hasps from patient 

lockers that could act as a point of attachment for a rope or cord and increase the risk of 

suicide. 

 

1 The Joint Commission was previously the “Joint Commission on Accreditation of Healthcare Organizations,” also 

known as JCAHO. 

VA Office of Inspector General 3 
Combined Assessment Program Review of the Northport VA Medical Center, Northport, New York 

Lockers in patient rooms on both acute psychiatry units contained a protruding metal 

looped eye hasp designed to attach an auxiliary lock. The eye hasps were located on the 

face of lockers at waist level and protruded sufficiently to act as a point of attachment 

that presented a risk of suicide by strangulation. 

Environmental Management Service (EMS) conducted a risk assessment of the acute 

psychiatric units in January 2007. The assessment included a timeline for correction and 

repair of several identified deficiencies. However, the eye hasps were not included in this 

assessment and remained a potential patient risk. 

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

Medical Center Director requires the modification or removal of looped eye hasps from 

patient lockers on the inpatient psychiatric units to improve patient safety. 

The VISN and the Acting Medical Center Directors agreed with the finding and 

recommendation and reported that EMS removed the looped eye hasps from patient 

lockers. This was completed by March 15, 2007. The improvement action is acceptable, 

and we consider the issue resolved. 

Computerized Patient Record System Business Rules 

The purpose of this review was to determine if the facility’s CPRS business rules 

complied with VHA regulations regarding limits about editing or amending patients’ 

medical records. VHA Handbook 1907.01, Health Information Management and Health 

Records, specifically states that, “No edit, reassignment, deletion, or alteration of any 

documentation after the manual or electronic signature has been completed can occur 

without the approval of the HIM [Health Information Management] professional or the 

Privacy Officer.” CPRS business rules are facility-specific and define the functions 

certain groups or individuals (such as clinicians) are allowed to perform in medical 

records within that facility. 

We reviewed VHA and medical center information and technology policies and 

interviewed Information Resource Management Service staff. A communication 

(software informational patch2

 USR*1*26) was sent from the VHA Office of Information 

(OI) on October 20, 2004, to all medical centers that addressed issues related to the 

editing of electronically signed documents in CPRS. The Information Officer cautioned, 

“The practice of editing a document that was signed by the author might have a patient 

safety implication and should not be allowed.” In addition, VHA issued a memorandum 

on June 7, 2006, to all VISN Directors instructing VA health care facilities to comply 

with the informational patch sent in October 2004. 

 

2

 A patch is a piece of code added to computer software in order to fix an identified problem. 

VA Office of Inspector General 4 
Combined Assessment Program Review of the Northport VA Medical Center, Northport, New York 

Condition Needing Improvement. The review found no business rules that allowed 

editing of a signed note by users other than the author. However, we found three 

business rules that allowed people other than the facility’s Chief of HIM Service or the 

Privacy Officer to amend or delete medical record documentation. Managers took action 

to remove the three rules while we were onsite. 

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

Medical Center Director requires that managers review CPRS business rules at least 

annually to guarantee compliance with VHA regulations. 

The VISN and Acting Medical Center Directors agreed with the finding and 

recommendation. They reported that the Veterans Health Information Systems and 

Technology Architecture/Imaging Work Group, a sub-group of the Information 

Management Committee, scheduled a review of CPRS business rules for April 2007, and 

the business rules will be reviewed semi-annually. The improvement actions are 

acceptable, and we will follow up on the reported implementation actions to ensure 

completion. 

Quality Management Program 

The medical center’s QM processes were generally satisfactory, and senior managers 

supported the program through participation in PI activities and allocation of resources. 

We followed up on a clinical reprivileging improvement item cited in the prior CAP 

report. The report suggested that clinical service chiefs be required to develop providerspecific performance data for reprivileging, and we found that managers had 

implemented this process. 

Conditions Needing Improvement. Managers needed to ensure that the facility’s 

equivalent to its Peer Review Committee (Patient Care Review Committee, [PCRC]) 

reports peer review activities at least quarterly to an appropriate medical staff executive 

committee. Managers also needed to improve PI reporting processes. 

Peer Review. As a result of an inspection of the facility’s peer review process by the 

OMI, we found that clinical managers revised their peer review processes and 

implemented OMI recommendations. However, VHA regulations require that the Peer 

Review Committee report at least quarterly to the Executive Committee of the Medical 

Staff (ECMS). At the time of the CAP inspection, clinical managers were not meeting 

this requirement. Managers told us that this was because non-clinicians were members of 

the Clinical Executive Board (CEB), the facility’s equivalent to the ECMS. Managers 

told us that they did not believe it was appropriate to report peer review activities to the 

CEB given its current membership. They also told us that they were in the process of 

assessing the board’s membership to include only clinicians in order to meet VHA peer 

review reporting regulations. 

VA Office of Inspector General 5 
Combined Assessment Program Review of the Northport VA Medical Center, Northport, New York 

Performance Improvement. We reviewed PI data and found that managers generally 

collected data appropriately. However, the facility did not have a dedicated PI/QM 

Committee. Consequently, we could not discern how managers consistently identified, 

implemented, and monitored improvement action items. PI managers reported that they 

sometimes followed up on this information either verbally or through electronic mail with 

service chiefs. Consequently, accountability for implementation and monitoring was 

fragmented and difficult to track. 

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

Medical Center Director requires that the PCRC report at least quarterly to the medical 

executive staff and that managers improve PI reporting processes to assure that PI action 

items are consistently identified, implemented, and monitored for efficacy by an 

appropriate monitoring committee. 

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

recommendations. They reported that managers revised the CEB policy and forwarded it 

to service chiefs for review. The target publication date is May 15, 2007, and the PCRC 

will report quarterly to the CEB beginning May 2007. Additionally, managers are 

establishing a PI/QM Committee with a target completion date of June 20, 2007. The 

improvement actions are acceptable, and we will follow up on the reported 

implementation actions to ensure completion. 

Other Observations 

Community Based Outpatient Clinics 

The purpose of this review was to evaluate CBOC compliance with VHA regulations 

regarding selected standards of operation, such as patient services, patient safety, 

credentialing and privileging, and the provision of emergency care. The review also 

assessed if the CBOC improved timely access to health care services. 

We visited the Plainview CBOC and interviewed primary care service line employees at 

the medical center and at the CBOC. We interviewed 10 CBOC patients and reviewed 

documents related to the CBOC’s description of services, specifically the management of 

patients prescribed the anti-coagulant medication warfarin. We also reviewed 

documentation related to credentialing and privileging and background investigations for 

three CBOC employees, and we inspected the CBOC’s EOC. 

Patient interviews indicated high levels of satisfaction with staff courtesy, quality of care, 

and timeliness of CBOC services, including mental health services. The Warfarin Clinic 

at the medical center appropriately managed CBOC patients receiving warfarin, and the 

three credentialing and privileging files were in order. We verified that background 

investigations for the three CBOC employees were completed. 

VA Office of Inspector General 6 
Combined Assessment Program Review of the Northport VA Medical Center, Northport, New York 

The CBOC facility was clean and well maintained. Veterans received services in 

surroundings that safeguarded their privacy, and medical records were stored securely. 

The emergency management plan was current, and clinical staff members were educated 

and knowledgeable about providing emergency care. Clinicians were trained in basic life 

support techniques. CBOC managers inspected the automated external defibrillator and 

kept documentation of the inspections current. We made no recommendations. 

Survey of Healthcare Experiences of Patients 

The SHEP survey, designed to promote improvement strategies that address patient 

defined needs and concerns, assesses patient experiences with inpatient and outpatient 

care services during a specified timeframe. 

The VHA Executive Career Field Performance plans for FYs 2006 and 2007 established 

the target goals. The expectation of the performance plan is that 76 percent of patients 

responding to the inpatient survey will rate their overall satisfaction as “very good” or 

“excellent.” Similarly, 77 percent of patients responding to the outpatient care survey 

will rate their overall satisfaction as “very good” or “excellent.” 

We reviewed the medical center’s SHEP results and compared them to the national and 

VISN results. The medical center’s inpatient results fell below target in five areas: 

(1) education and information, (2) emotional support, (3) family involvement, 

(4) preferences, and (5) transition. However, four of these five areas were above the 

VISN’s results. 

The outpatient SHEP results showed the medical center’s scores were below the national 

target in two areas (1) education & information and (2) pharmacy pick-up. However, 

both of the areas were above the VISN’s results. 

The medical center’s managers analyzed the scores, identified areas for improvement, 

and developed and implemented acceptable improvement strategies. Strategies to 

improve inpatient survey results included patient satisfaction surveys completed during 

inpatient admissions and after discharge and the development of a unit ambassador 

program that addressed patient satisfaction on a unit level. 

To improve outpatient survey results, managers opened a new patient education center 

and increased staffing in the primary care call center. 

Managers monitored the efficacy of the improvement strategies and communicated the 

results to staff through facility-wide and service-specific committees. Because of the 

actions managers had already taken, we made no recommendations. 

VA Office of Inspector General 7 
Combined Assessment Program Review of the Northport VA Medical Center, Northport, New York 

Patient Transportation Services 

The purpose of the original review reported in the Combined Assessment Program 

Review of the Northport VA Medical Center, Northport, New York, Report No. 04-00403-

128, April 14, 2004, was to determine if health care facilities had internal controls that 

supported safe patient transportation programs. The 2004 report suggested that the 

medical center should implement the following improvement actions: (a) ensure that 

employees who transport patients be properly screened and trained, (b) ensure that 

documentation of training be maintained, and (c) ensure that patient transportation duties 

be incorporated into the employees’ position descriptions and performance evaluations. 

We reviewed two records of employees who transported patients as part of their duties. 

We found that managers verified that the employees completed annual driver safety 

training, held current drivers licenses, and maintained safe driving records. Additionally, 

the review verified that Employee Health performed physical examinations for the two 

employees within appropriate timeframes, and patient transportation duties were included 

in the employees’ position descriptions and performance evaluations. These actions 

appropriately addressed the suggestions from the prior CAP report; therefore, we made 

no recommendations. 

VA Office of Inspector General 8 
Combined Assessment Program Review of the Northport VA Medical Center, Northport, New York

Appendix A 

VISN Director Comments 

Department of 

Veterans Affairs Memorandum

Date: March 29, 2007 

From: Director, New York/New Jersey Veterans Healthcare 

System (10N3) 

Subject: CAP Review of the Northport VA Medical Center 

Northport, New York 

To: Assistant Inspector General for Healthcare Inspections 

(54) 

Attached please find the response to the draft CAP Report 

for the program review of the Northport VA Medical 

Center, Northport, New York. The VISN concurs with 

the action plan submitted by the facility. 

 (original signed by:)

JAMES J. FARSETTA, FACHE 

VA Office of Inspector General 9 
Combined Assessment Program Review of the Northport VA Medical Center, Northport, New York

Appendix B 

Acting Medical Center Director Comments 

Department of 

Veterans Affairs Memorandum

Date: March 29, 2007 

From: Acting Director, Northport VA Medical Center (632) 

Subject: CAP Review of the Northport VA Medical Center 

Northport, New York 

To: Assistant Inspector General for Healthcare Inspections 

(54) 

This is to acknowledge receipt and review of the draft 

CAP Report for Northport VA Medical Center, Northport, 

New York. Thank you for the opportunity to comment on 

the recommendations for improvement contained in this 

report. If you have any questions, please contact Florence 

Fallon, RN, at 631-261-4400, ext. 2749. 

 (original signed by:) 

GERALD CULLITON 

VA Office of Inspector General 10 
Combined Assessment Program Review of the Northport VA Medical Center, Northport, New York

Acting Director’s Comments 

to Office of Inspector General’s Report 

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

recommendations in the Office of Inspector General report: 

OIG Recommendations

Recommendation 1. We recommended that the VISN Director ensure that 

the Acting Medical Center Director require the modification or removal of 

looped eye hasps from patient lockers on the inpatient psychiatric units to 

improve patient safety. 

Concur Target Completion Date: March 15, 2007 

EMS removed the looped eye hasps from patient lockers on the inpatient 

psychiatric units. This was completed as of the above date. 

Recommendation 2. We recommended that the VISN Director ensure that 

the Acting Medical Center Director requires that managers review CPRS 

business rules at least annually to guarantee compliance with VHA 

regulations. 

Concur Target Completion Date: March 26, 2007 

CPRS Business Rules are scheduled to be reviewed at the April 2007 

meeting of the VISTA/Imaging work group a sub group of the Information 

Management Committee. There after, CPRS Business Rules to be 

reviewed semi-annually. 

Recommendation 3. We recommended that the VISN Director ensure that 

the Acting Medical Center Director requires that the PCRC report at least 

quarterly to the medical executive staff and that managers improve PI 

reporting processes to assure that PI action items are consistently identified, 

implemented, and monitored for efficacy by an appropriate monitoring 

committee. 

Concur Target Completion Date: June 20, 2007 

VA Office of Inspector General 11 
Combined Assessment Program Review of the Northport VA Medical Center, Northport, New York

CEB policy revised and forwarded to service chiefs for review. The target 

date for publication is May 15, 2007. Peer Review Committee will submit 

next quarterly report to the Clinical Executive Board in May 2007 and 

quarterly thereafter. 

A Performance Improvement/Quality Management Committee is being 

established as a monitoring committee to ensure performance improvement 

action items are consistently identified, implementation plans documented, 

and employees who are accountable for implementing action plans report 

their progress toward implementation and the efficacy of the actions to this 

committee. Medical center memorandum drafted and forwarded to Service 

Chiefs for review. The target date for publication is May 15, 2007. Target 

date for first meeting of this committee is June 2007. 

 

VA Office of Inspector General 12 
Combined Assessment Program Review of the Northport VA Medical Center, Northport, New York

Appendix C 

OIG Contact and Staff Acknowledgments 

OIG Contact Katherine Owens, MSN 

Director, Boston Office of Healthcare Inspections 

(781) 687-2317 

Acknowledgments Annette Acosta, MN, FNP, RN 

Jeanne Martin, Pharm D 

Sunil Sen-Gupta, PhD, MPH 

VA Office of Inspector General 13 
Combined Assessment Program Review of the Northport VA Medical Center, Northport, New York

Appendix D 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, Veterans Integrated Service Network 3 (10N3) 

Acting Director, Northport VA Medical Center (632/00) 

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: Hillary Rodham Clinton, Charles E. Schumer 

U.S. House of Representative: Steve Israel 

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

VA Office of Inspector General 14