Department of Veterans Affairs 

Office of Inspector General 

Office of Healthcare Inspections
 

Report No.10-03090-87

Combined Assessment Program
 

Review of the
 

VA Connecticut Healthcare System
 

West Haven, Connecticut
 

February 14, 2011
 

Washington, DC 20420
 
Why We Did This Review 

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

General's (OIG's) efforts to ensure that high quality health care is 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 missions of providing veterans 

convenient access to high quality medical services. 

 Provide crime awareness briefings 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 

Telephone: 1-800-488-8244 

E-Mail: vaoighotline@va.gov 

(Hotline Information: http://www.va.gov/oig/contacts/hotline.asp) 
CAP Review of the VA Connecticut Healthcare System, West Haven, CT 

Glossary 

C&P credentialing and privileging 

CAP Combined Assessment Program 

CBOC community based outpatient clinic 

CHF congestive heart failure 

CLC community living center 

COC coordination of care 

EOC environment of care 

facility VA Connecticut Healthcare System 

FPPE Focused Professional Practice Evaluation 

FTE full-time employee equivalents 

FY fiscal year 

MDRO multidrug-resistant organisms 

OIG Office of Inspector General 

PRRTP Psychosocial Residential Rehabilitation Treatment 

Program 

PSB Professional Standards Board 

QM quality management 

SOPs standard operating procedures 

VHA Veterans Health Administration 

VISN Veterans Integrated Service Network 

VA OIG Office of Healthcare Inspections 
CAP Review of the VA Connecticut Healthcare System, West Haven, CT 

Table of Contents 

Page 

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

Objectives and Scope................................................................................................ 1
 

Objectives ............................................................................................................... 1
 

Scope...................................................................................................................... 1
 

Reported Accomplishments...................................................................................... 2
 

Results ........................................................................................................................ 2
 

Review Activities With Recommendations .............................................................. 2
 

Physician C&P................................................................................................... 2
 

COC .................................................................................................................. 3
 

Review Activities Without Recommendations ......................................................... 4
 

EOC................................................................................................................... 4
 

Management of MDRO...................................................................................... 4
 

Management of Test Results............................................................................. 4
 

Medication Management ................................................................................... 5
 

QM..................................................................................................................... 5
 

Comments................................................................................................................... 5
 

Appendixes 

A. Facility Profile .................................................................................................... 6
 

B. Follow-Up on Previous Recommendations........................................................ 7
 

C. VHA Satisfaction Surveys and Hospital Outcome of Care Measures................ 9
 

D. VISN Director Comments .................................................................................. 11
 

E. Acting Facility Director Comments..................................................................... 12
 

F. OIG Contact and Staff Acknowledgments ......................................................... 14
 

G. Report Distribution ............................................................................................ 15
 

VA OIG Office of Healthcare Inspections 
 

Executive Summary: Combined Assessment Program 

Review of the VA Connecticut Healthcare System, 

West Haven, CT 

Review Purpose: The purpose was 

to evaluate selected activities, focusing 

on patient care administration and 

quality management, and to provide 

crime awareness training. We 

conducted the review the week of 

December 6, 2010. 

Review Results: The review covered 

seven activities. We made no 

recommendations in the following five 

activities: 

	 Environment of Care 

	 Management of Multidrug-Resistant 

Organisms 

	 Management of Test Results 

	 Medication Management 

	 Quality Management 

The facility’s reported accomplishments 

were system improvements in fee basis 

care and the creation of an innovative 

tool to track and trend environment of 

care rounds. 

Recommendations: We made 

recommendations in the following two 

activities: 

Physician Credentialing and Privileging: 

Ensure that newly hired providers’ 

profiles include Focused Professional 

Practice Evaluation data and that 

Professional Standards Board meeting 

minutes reflect criteria and outcome 

results of Focused Professional Practice 

Evaluations. 

Coordination of Care: Strengthen 

processes to ensure that advance 

directive screenings and appropriate 

follow-up are performed and 

documented. 

Comments 

The Veterans Integrated Service 

Network and Acting Facility Directors 

agreed with the Combined Assessment 

Program review findings and 

recommendations and provided 

acceptable improvement plans. 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 OIG Office of Healthcare Inspections i 
CAP Review of the VA Connecticut Healthcare System, West Haven, CT 

Objectives and Scope 

Objectives
 

Scope
 

CAP reviews are one element of the OIG’s efforts to ensure 

that our Nation’s veterans receive high quality VA health care 

services. The objectives of the CAP review are to: 

	 Conduct recurring evaluations of selected health care 

facility operations, focusing on patient care administration 

and QM. 

	 Provide crime awareness briefings to increase employee 

understanding of the potential for program fraud and the 

requirement to refer suspected criminal activity to the 

OIG. 

We reviewed selected clinical and administrative 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 care to identify and correct harmful and 

potentially harmful practices and conditions. 

In performing the review, we inspected selected areas, 

interviewed managers and employees, and reviewed clinical 

and administrative records. The review covered the 

following seven activities: 

	 COC 

	 EOC 

	 Management of MDRO 

	 Management of Test Results 

	 Medication Management 

	 Physician C&P 

	 QM 

The review covered facility operations for FY 2009 and 

FY 2010 and was done in accordance with OIG SOPs for 

CAP reviews. We also followed up on recommendations 

from our prior CAP review of the facility (Combined 

Assessment Program Review of the VA Connecticut 

Healthcare System, West Haven, Connecticut, Report 

No. 07-03174-184, August 13, 2008). The facility had 

VA OIG Office of Healthcare Inspections 1 
CAP Review of the VA Connecticut Healthcare System, West Haven, CT 

corrected all findings from our previous review. (See 

Appendix B for further details.) 

During this review, we also presented crime awareness 

briefings for 105 employees. These briefings covered 

procedures for reporting suspected criminal activity to the 

OIG and included case-specific examples illustrating 

procurement fraud, conflicts of interest, and bribery. 

In this report, we make recommendations for improvement. 

Recommendations pertain to issues that are significant 

enough to be monitored by the OIG until corrective actions 

are implemented. 

Reported Accomplishments 

System	 Through system improvements in fee basis care, the facility 

was able to realize a savings of more than $4 million for Improvements in FY 2010. Managers established a Fee Basis Oversight Fee Basis Care Committee and implemented key strategic initiatives. For 

example, facility managers expanded the endoscopy suite, 

enabling all colonoscopies to be performed onsite, and 

activated a second cardiac catheterization room with 24-hour 

coverage so that all cardiac catheterizations could be 

performed at the facility rather than on a fee basis. 

EOC Tracking Tool	 The facility created an innovative tool to track and trend EOC 

rounds. The EOC Committee worked with a computer 

programmer to build an intuitive database aimed at tracking 

and trending issues that are important to VHA and the 

facility. This interdisciplinary tool has allowed for a more 

critical and comprehensive review of the facility’s 

environment and has increased identification of potential 

deficiencies. Previously, the team conducting EOC rounds 

collectively reviewed 54 items related to EOC. The new tool 

contains 191 EOC criteria, allowing for a more 

comprehensive review. 

Results 

Review Activities With Recommendations 

Physician C&P	 The purpose of this review was to determine whether the 

facility had consistent processes for physician C&P that 

complied with applicable requirements. 

We reviewed 21 physicians’ C&P files and profiles and found 

that licenses were current and that primary source 

VA OIG Office of Healthcare Inspections 2 
CAP Review of the VA Connecticut Healthcare System, West Haven, CT 

verification had been obtained. However, we identified the 

following area that needed improvement. 

FPPE. VHA policy requires facilities to evaluate the 

privilege-specific competence of a practitioner who does not 

have documented evidence of competently performing the 

requested privileges at the facility.1 Consideration of an 

FPPE is to occur at the time of initial appointment to the 

medical staff or when requesting new privileges. We did not 

find FPPEs for five of the six newly hired physicians. In 

addition, PSB meeting minutes did not reflect criteria or the 

outcome results of FPPE, as required by VHA policy. 

Recommendation	 1. We recommended that newly hired providers’ profiles 

include FPPE data and that PSB meeting minutes reflect 

criteria and outcome results of FPPE. 

COC	 The purpose of this review was to evaluate whether the 

facility managed advance care planning, advance directives, 

and discharges in accordance with applicable requirements. 

We reviewed patients’ medical records for evidence of 

advance care planning, advance directives, and discharge 

instructions. We identified the following area that needed 

improvement. 

Advance Directive Screening and Follow-Up. VHA requires 

notification and screening regarding advance directives upon 

a patient’s admission to an inpatient facility.2 VHA also 

requires that the notification and screening be documented in 

the patient’s medical record. Facility policy requires that 

nursing staff refer patients who request further information on 

advance directives to Social Work Service. Our review of 

10 medical records found that facility staff documented 

notification for all 10 patients. However, for six (60 percent) 

of the patients, facility staff did not ask and/or document in 

the medical records whether the patients had advance 

directives. In addition, we found one case in which a patient 

expressed interest in preparing an advance directive, but 

there was no follow-up by facility staff to assist the patient. 

Recommendation	 2. We recommended that processes be strengthened to 

ensure that advance directive screenings and appropriate 

follow-up are performed and documented. 

1 VHA Handbook 1100.19, Credentialing and Privileging, November 14, 2008.
 2 VHA Handbook 1004.02, Advance Care Planning and Management of Advance Directives, July 2, 2009.
 

VA OIG Office of Healthcare Inspections 3 
CAP Review of the VA Connecticut Healthcare System, West Haven, CT 

Review Activities Without Recommendations 

EOC
 

Management of 

MDRO 

Management of 

Test Results 

The purpose of this review was to determine whether the 

facility maintained a safe and clean health care environment 

in accordance with applicable requirements. 

We inspected a medical unit, a surgical unit, the medical 

intensive care unit, a mental health unit, the CLC, radiology 

(including nuclear medicine), and the emergency 

department. The facility maintained a generally clean and 

safe environment. 

When facilities use N95 respirators, the Occupational Safety 

and Health Administration requires that designated 

employees be fit tested annually. We reviewed fit test 

records for 25 employees for the 12-month 

period January 2009–December 2010 and found that 

22 (88 percent) employees did not have the required annual 

fit testing. Facility managers were already aware of the issue 

and provided documentation that the number of designated 

employees had significantly increased in the past 2 years, 

overwhelming the fit testing program. Facility managers are 

working closely with VISN managers to ensure that all 

designated employees are fit tested as required. In the 

interim, other protective masks that do not require fit testing 

have been made available to employees in high-risk areas. 

Therefore, we made no recommendation. 

The purpose of this review was to evaluate whether the 

facility had developed a safe and effective program to reduce 

the incidence of MDRO in its patient population in 

accordance with applicable requirements. 

We reviewed the facility’s infection control risk assessment, 

employee training records, and medical records. We 

inspected a medical/surgical unit and a medical intensive 

care unit and interviewed employees. We determined that 

the facility had an effective program in place. We made no 

recommendations. 

The purpose of this review was to follow up on a previous 

review that identified improvement opportunities related to 

documentation of notification of abnormal test results and 

follow-up actions taken.3 

3 Healthcare Inspection Summary Review – Evaluation of Veterans Health Administration Procedures for 

Communicating Abnormal Test Results, Report No. 01-01965-24, November 25, 2002. 

VA OIG Office of Healthcare Inspections 4 
CAP Review of the VA Connecticut Healthcare System, West Haven, CT 

We reviewed the facility’s policies and procedures, the 

process for monitoring communication of test results, and the 

medical records of patients who had tests resulting in critical 

values and normal values. We determined that the facility 

had implemented an effective reporting process for test 

results. We made no recommendations. 

Medication	 The purpose of this review was to determine whether the 

Management facility employed safe practices in the preparation, transport, 

and administration of hazardous medications, specifically 

chemotherapy, in accordance with applicable requirements. 

We observed the compounding and transportation of 

chemotherapy medications and the administration of those 

medications in the oncology clinic, and we interviewed 

employees. We determined that the facility safely prepared, 

transported, and administered the medications. We made no 

recommendations. 

QM	 The purpose of this review was to evaluate whether the 

facility had a comprehensive QM program in accordance with 

applicable requirements and whether senior managers 

actively supported the program’s activities. 

We interviewed senior managers and QM personnel, and we 

evaluated policies, meeting minutes, and other relevant 

documents. The QM program was generally compliant with 

requirements, and senior managers supported the program. 

We made no recommendations. 

Comments 

The VISN and Acting Facility Directors agreed with the CAP review findings and 

recommendations and provided acceptable improvement plans. (See Appendixes D 

and E, pages 11–13, for the full text of the Directors’ comments.) We will follow up on 

the planned actions until they are completed. 

VA OIG Office of Healthcare Inspections 5 
CAP Review of the VA Connecticut Healthcare System, West Haven, CT 

Appendix A 

Facility Profile4 

Type of Organization Tertiary care medical center 

Complexity Level 1a 

VISN 1 

CBOCs Danbury, CT 

Newington, CT 

New London, CT 

Stamford, CT 

Waterbury, CT 

Willimantic, CT 

Winsted, CT 

Veteran Population in Catchment Area 253,800 

Type and Number of Total Operating Beds: 

 Hospital, including PRRTP 190 

 CLC 40 

Medical School Affiliations Yale University 

University of Connecticut 

 Number of Residents 170 

FY 2010 (entire FY 

except where 

noted) 

Prior FY 

Resources (in millions): 

 Total Medical Care Budget $385 (through 

June 2010) 

$390 

 Medical Care Expenditures $385 (through 

June 2010) 

$390 

Total Medical Care FTE 2,186.9 (through 

June 2010) 

2,111.1 

Workload: 

 Number of Station Level Unique 

Patients 

48,527 (through 

May 2010) 

55,398 

 Inpatient Days of Care: 

o Acute Care 58,744 60,365 

o CLC/Nursing Home Care Unit 10,052 10,399 

Hospital Discharges 5,733 5,438 

Total Average Daily Census (including all bed 

types) 

188.5 193.9 

Cumulative Occupancy Rate 82% 84% 

Outpatient Visits 409,092 605,056 

4 All data provided by facility management. 

VA OIG Office of Healthcare Inspections 6 
CAP Review of the VA Connecticut Healthcare System, West Haven, CT 

Appendix B 

Follow-Up on Previous Recommendations 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

COC 

1. Comply with VHA and facility policies 

governing inter-facility transfers. 

The “W-10/Interfacility Transfer 

(10-2649A)” form is in use, and 

compliance is monitored. Facility 

policy appropriately reflects changes in 

the process. 

Y N 

2. Comply with facility policy governing 

intra-facility transfers. 

A modified template including all 

required elements is now in use in the 

Computerized Patient Record System, 

and compliance is monitored. 

Y N 

EOC 

3. Initiate pest control measures to eliminate 

fruit flies on the acute psychiatry unit. 

A pest control review was conducted 

on the unit, and measures were taken 

to eliminate items that attract fruit flies. 

Y N 

4. Ensure the hole between the acute 

psychiatry unit’s nutrition kitchen and 

housekeeping closet is sealed. 

The issue was corrected during the 

previous CAP visit. The hole between 

the nutrition kitchen and the 

housekeeping closet was sealed. 

Y N 

5. Ensure that acute psychiatry bathrooms 

and showers are cleaned regularly to 

eliminate and prevent mold. 

Showers are on a regular cleaning 

schedule to prevent mold growth. 

Y N 

6. Replace standard screws with 

tamper-proof screws on the acute psychiatry 

unit. 

Tamper-proof screws are in use 

throughout the unit. 

Y N 

VA OIG Office of Healthcare Inspections 7 
CAP Review of the VA Connecticut Healthcare System, West Haven, CT 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

7. Reduce the risk of fire by inspecting and 

cleaning the acute psychiatry unit’s clothes 

dryer vent on a regular basis and securing 

the area around the dryer to prevent objects 

from falling behind and causing a fire 

hazard. 

Unit staff perform inspections and 

cleaning of the unit’s clothes dryer 

vent. Dryer vents are regularly 

inspected during EOC rounds. 

Y N 

8. Eliminate potential exposure to 

secondhand smoke. 

The smoking shelter’s door and 

exhaust system were repaired and are 

in proper working order. 

Y N 

VA OIG Office of Healthcare Inspections 8 
CAP Review of the VA Connecticut Healthcare System, West Haven, CT 

Appendix C 

VHA Satisfaction Surveys
 VHA has identified patient and employee satisfaction scores as significant indicators of 

facility performance. Patients are surveyed monthly. Table 1 below shows facility, 

VISN, and VHA overall inpatient and outpatient satisfaction scores and targets for 

quarters 1–3 of FY 2010. 

Table 1 

FY 2010 

(inpatient target = 64, outpatient target = 56) 

Inpatient 

Score 

Quarter 1 

Inpatient 

Score 

Quarter 2 

Inpatient 

Score 

Quarter 3 

Outpatient 

Score 

Quarter 1 

Outpatient 

Score 

Quarter 2 

Outpatient 

Score 

Quarter 3 

Facility 62.7 57.9 56.6 57.7 55.0 62.5 

VISN 69.3 69.6 64.1 61.0 61.1 62.7 

VHA 63.3 63.9 64.5 54.7 55.2 54.8 

Employees are surveyed annually. Figure 1 below shows the facility’s overall employee 

scores for 2008, 2009, and 2010. Since no target scores have been designated for 

employee satisfaction, VISN and national scores are included for comparison. 

VA OIG Office of Healthcare Inspections 9 
CAP Review of the VA Connecticut Healthcare System, West Haven, CT 

Hospital Outcome of Care Measures
 Hospital Outcome of Care Measures show what happened after patients with certain 

conditions5 received hospital care. The mortality (or death) rates focus on whether 

patients died within 30 days of their hospitalization. The rates of readmission focus on 

whether patients were hospitalized again within 30 days. Mortality rates and rates of 

readmission show whether a hospital is doing its best to prevent complications, teach 

patients at discharge, and ensure patients make a smooth transition to their home or 

another setting. The hospital mortality rates and rates of readmission are based on 

people who are 65 and older. These comparisons are “adjusted” to take into account 

their age and how sick patients were before they were admitted to the VA facility. 

Table 2 below shows the facility’s Hospital Outcome of Care Measures for 

FYs 2006–2009. 

Table 2 

Mortality Readmission 

Heart Attack CHF Pneumonia Heart Attack CHF Pneumonia 

Facility 14.24 9.19 14.1 20.25 19.21 14.87 

VHA 13.31 9.73 15.08 20.57 21.71 15.85 

5 A heart attack (also called acute myocardial infarction) happens when blood flow to a section of the heart muscle 

becomes blocked and the blood supply is slowed or stopped. If the blood flow is not restored in a timely manner, 

the heart muscle becomes damaged from lack of oxygen. CHF is a weakening of the heart’s pumping power. With 

heart failure, your body does not get enough oxygen and nutrients to meet its needs. Pneumonia is a serious lung 

infection that fills your lungs with mucus and causes difficulty breathing, fever, cough, and fatigue. 

VA OIG Office of Healthcare Inspections 10 
CAP Review of the VA Connecticut Healthcare System, West Haven, CT 

Appendix D 

VISN Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: January 25, 2011 

From: Director, VA New England Healthcare System (10N1) 

Subject: CAP Review of the VA Connecticut Healthcare System, 

West Haven, CT 

To: Director, Bedford Office of Healthcare Inspections (54BN) 

Director, Management Review Service (VHA CO 10B5 Staff) 

I concur with the recommendations and action plans in the attached 

memorandum from VA Connecticut Healthcare System. 

(original signed by:) 

MICHAEL MAYO-SMITH 

VA OIG Office of Healthcare Inspections 11 
CAP Review of the VA Connecticut Healthcare System, West Haven, CT 

Appendix E 

Acting Facility Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: January 25, 2011 

From: Acting Director, VA Connecticut Healthcare System (689/00) 

Subject: CAP Review of the VA Connecticut Healthcare System, 

West Haven, CT 

To: Director, VA New England Healthcare System (10N1) 

This memorandum serves as our concurrence with the recommendations 

found in this CAP Review of VA Connecticut Healthcare System which 

was conducted in December, 2010. The implementation plan, showing 

specific corrective actions and target completion dates, is attached. 

(original signed by:) 

VINCENT NG 

VA OIG Office of Healthcare Inspections 12 
CAP Review of the VA Connecticut Healthcare System, West Haven, CT 

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 newly hired providers’ profiles include 

FPPE data and that PSB meeting minutes reflect criteria and outcome results of FPPE. 

Concur. 

IMPLEMENTATION PLAN: VA Connecticut Healthcare System convened a Clinical 

Operations meeting, a subcommittee of the Medical Staff Executive Committee 

including all the clinical service chiefs, regarding improvements needed to the FPPE 

process and data on December 14, 2010. Corrective actions that were identified 

included (1) improvements in PSB minutes would be expected to reflect the criteria and 

outcome of the FPPE effective at the very next PSB. These minutes would be 

prospectively validated for accuracy and completeness in terms of criteria and outcome 

of the FPPE by the Associate Chief of Staff. This will be reported to the Chief, Quality 

Management on a regular basis for a period no less than 3 months. Documentation will 

be available through the CQI Council meeting. Additionally, (2) any newly hired 

providers’ profile will include a newly-developed individualized FPPE, which will be 

reviewed prospectively by the Associate Chief of Staff and Chief of Staff. This will be 

reported to the Chief, Quality Management on a regular basis for a period no less than 

3 months. Documentation will be available through the CQI Council meeting. 

TARGET COMPLETION DATE: April 25, 2011 (3 data points to assure sustainment) 

Recommendation 2. We recommended that processes be strengthened to ensure that 

advance directive screenings and appropriate follow-up are performed and 

documented. 

Concur. 

IMPLEMENTATION PLAN: VA Connecticut Healthcare System immediately discussed 

this issue with the key stakeholders and is in the process of flow-mapping the process 

to use this as an opportunity to apply the VA-TAMMCS (System Redesign) model. The 

implementation plan will be, upon concurrence of the correct work flow, to provide 

education to both Nursing and Social Work on the expectations with real time data 

available regarding performance. This will serve as the baseline data. From that point, 

monitoring of the compliance with both screening and appropriate follow-up with 

feedback provided monthly to the stakeholders and the CQI Council for a period no less 

than 3 months. This will be reported to the Chief, Quality Management on a regular 

basis for a period no less than 3 months. Documentation will be available through the 

CQI Council meeting. 

TARGET COMPLETION DATE: May 25, 2011 (3 data points to assure sustainment) 

VA OIG Office of Healthcare Inspections 13 
CAP Review of the VA Connecticut Healthcare System, West Haven, CT 

Appendix F 

OIG Contact and Staff Acknowledgments 

Contact	 Claire McDonald, MPA, CFE 

Bedford Office of Healthcare Inspections 

Contributors	 Glen Pickens, Sr., RN, BSN, MHSM, Team Leader 

Elaine Kahigian, RN, JD 

Frank Keslof, EMT, BSBA, MHA 

Jeanne Martin, PharmD 

Lynn Sweeney, MD 

Robert Breunig, Special Agent, Office of Investigations 

VA OIG Office of Healthcare Inspections 14 
CAP Review of the VA Connecticut Healthcare System, West Haven, CT 

Appendix G 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VA New England Healthcare System (10N1) 

Acting Director, VA Connecticut Healthcare System (689/00) 

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: Richard Blumenthal, Joseph I. Lieberman 

U.S. House of Representatives: Rosa L. DeLauro 

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

VA OIG Office of Healthcare Inspections 15