Department of Veterans Affairs
 

Office of Inspector General
 

Healthcare Inspection
 

Alleged Poor Quality of Care in
 

Radiation Therapy
 

VA Long Beach Healthcare System
 

Long Beach, California
 

Report No. 10-03861-119 March 9, 2011
 VA Office of Inspector General
 

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

Telephone: 1-800-488-8244 

E-Mail: vaoighotline@va.gov
	

(Hotline Information: http://www.va.gov/oig/contacts/hotline.asp) 
Alleged Poor Quality of Care in Radiation Therapy, VA Long Beach Healthcare System, Long Beach, CA 

Executive Summary
 

The VA Office of Inspector General Office of Healthcare Inspections conducted an 

inspection to determine the validity of allegations regarding radiation therapy (RT) at the 

VA Long Beach Healthcare System (the facility) in Long Beach, CA. Allegations 

included: 

 Inappropriate care 

 Lack of competence of radiation oncologists 

 Lack of communication with facility leadership about adverse events 

 Hostile work environment 

We substantiated the allegation of poor care for 1 of the 10 patients reported and 

identified deficiencies in medical record documentation for 9 of the 10 patients. We also 

substantiated that facility leaders were not aware of adverse patient outcomes in RT and 

found that action was not taken to correct deficiencies identified in peer reviews. 

We did not substantiate the allegation that radiation oncologists lacked competence. 

We recommended that the VISN Director require that the Facility Director (1) ensures 

that an external peer review assessment of the treatment provided by radiation 

oncologists for Patient 1 is performed; (2) evaluates the care of Patient 1 with Regional 

Counsel for possible disclosure to the patient; (3) ensures that RT medical record 

documentation complies with VHA policy and ACR guidelines; and (4) ensures that RT 

patient outcomes are monitored by the Quality Management program and others external 

to the RT department to oversee the implementation of corrective actions for all adverse 

patient outcomes. 

The VISN and facility Directors agreed with our findings and recommendations. The 

implementation plans are acceptable, and we will follow up on the planned actions until 

they are completed. 

VA Office of Inspector General i 
Alleged Poor Quality of Care in Radiation Therapy, VA Long Beach Healthcare System, Long Beach, CA 

DEPARTMENT OF VETERANS AFFAIRS
 

Office of Inspector General
 

Washington, DC 20420
 

TO:	 Director, Veterans Integrated Service Network 22 

SUBJECT:	 Healthcare Inspection – Alleged Poor Quality of Care in Radiation 

Therapy, VA Long Beach Healthcare System, Long Beach, California 

Purpose

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

an inspection to determine the validity of allegations regarding poor quality of care in 

radiation therapy at the VA Long Beach Healthcare System (the facility) in 

Long Beach, CA. 

Background

The OIG Hotline Division received allegations that the facility’s Radiation Therapy 

Service provided inappropriate radiation therapy (RT) care to 10 patients. Allegations 

included: 

 Inappropriate care 

 Lack of competence of radiation oncologists 

 Lack of communication with facility leadership about adverse events 

 Hostile work environment 

The facility, part of Veterans Integrated Service Network (VISN) 22, has 231 acute care 

beds and 91 long-term care beds. It provides primary, secondary, and tertiary care for 

183,000 veterans. Affiliations include the University of California at Irvine, the 

California State University at Long Beach, and the University of Southern California. At 

the time of our review, RT was provided by full-time radiation oncologists. 

RT is used to treat cancer and other abnormal cell growth while protecting normal cells 

as much as possible. In the most common form of RT, external beam RT, intense 

radiation from linear accelerators is directed at tumors. With intensity-modulated RT 

(IMRT), higher doses can be delivered to abnormal tissue while reducing exposure of 

VA Office of Inspector General 1 
Alleged Poor Quality of Care in Radiation Therapy, VA Long Beach Healthcare System, Long Beach, CA 

adjacent non-target structures, resulting in fewer side effects.1 The severity of side 

effects varies depending on the part of the body being treated and whether the patient is 

also receiving chemotherapy. Common side effects from RT include fatigue, diarrhea, 

hair loss, and abnormalities of the skin and urinary tract.2 

With the higher doses of radiation used in IMRT, there is an increased risk of harm to 

patients. Practice guidelines and documentation requirements aim to maximize patient 

safety.3 Examples of documentation requirements include weekly clinical treatment 

management notes and summaries at the completion of treatment. 4 

Effective quality management (QM) requires an organized, systematic approach to 

planning, delivering, measuring, and improving health care.5 Peer review is a key 

organizational function contributing to quality improvement. In addition to assessments 

of specific instances of care in response to an adverse patient outcome, peer review 

encompasses the ongoing evaluation of professional practice.6 

Scope and Methodology

We conducted a telephone interview with the complainant to clarify the allegations prior 

to a site visit November 15–16, 2010. We interviewed managers and employees and 

reviewed pertinent VHA policies and procedures, facility documents, credentialing and 

privileging (C&P) information, and medical records. We did not address the allegation 

of a hostile work environment in this report. 

We conducted the inspection in accordance with Quality Standards for Inspection and 

Evaluation published by the Council of the Inspectors General on Integrity and 

Efficiency. 

Inspection Results

Issue 1: Quality of Care and Competence

We substantiated the allegation of inappropriate RT care for 1 of the 10 subject patients. 

We also found deficiencies in the documentation of treatment for 9 of the 10 patients. 

We did not substantiate the allegation that radiation oncologists lacked competence. The 

C&P folders and profiles of the radiation oncologists complied with VHA policy. In 

1 American College of Radiology. Practice Guidelines for Intensity-Modulated Radiation Therapy (IMRT), 2007.
 2 U.S. National Institutes of Health, National Cancer Institute, “Radiation Therapy Side Effects.”
 3 American College of Radiology, Practice Guidelines for Radiation Oncology, rev. 2009.
 4 American College of Radiology, Practice Guideline for Communication: Radiation Oncology, rev. 2009.
 5 VHA Directive 2009-023, Quality Management System, September 11, 2009.
 6 VHA Directive 2010-025, Peer Review for Quality Management, June 3, 2010.
 

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Alleged Poor Quality of Care in Radiation Therapy, VA Long Beach Healthcare System, Long Beach, CA 

addition, peer reviews for ongoing professional practice evaluations were appropriately 

documented. 

Patient 1 

Case Review. A patient was diagnosed with squamous cell carcinoma of the right tonsil 

with metastasis to retropharyngeal lymph nodes. He underwent IMRT and 3D conformal 

RT in May and June 2010. During and after IMRT, concerns included sore throat, hoarse 

voice, and moderate erythema of the skin involving breakdown on both sides of the neck. 

IMRT treatments were suspended in early June to avoid further skin breakdown. The 

treatment plan was modified without new scan images, and the patient was started on 3D 

conformal RT 5 days later with minimal documentation explaining the treatment change. 

Although the patient’s condition subsequently improved, at 3 months after treatment, he 

continued to have dry mouth and was unable to tolerate solid foods. 

Case Findings. We substantiated the allegation that this patient received inappropriate 

care during the course of RT. The radiation prescription did not spare the parotid gland 

on the side opposite the tumor, and the patient was not referred for Speech Pathology 

consultation after experiencing swallowing difficulties.7 Additionally, progress notes 

required during treatment were not entered, and the treatment summary lacked details 

about treatment dates, patient response, and radiation dose. 

Patient 2 

Case Review. A patient with a past history of prostatectomy and hormone therapy8 

underwent IMRT for prostate cancer in late 2009 and early 2010. The patient had urinary 

frequency, dysuria, and diarrhea during and after RT. He underwent cystoscopies in 

September 2009, May 2010, and July 2010. Radiation urethritis9 was diagnosed, and the 

patient was treated with hyperbaric oxygen (HBO) therapy. A total of 30 treatments were 

administered prior to resolution of symptoms. 

Case Findings. We did not substantiate the allegation of inappropriate RT care. We 

found that treatment was appropriate and the side effects anticipated. However, treatment 

documentation had discrepancies with respect to cumulative dose and type of treatment 

given. 

7 American College of Radiology, Practice Guideline for Radiation Oncology, rev. 2009.
 8 Treatment to stop testosterone from being released in order to manage the growth of remaining prostate cancer
 

cells.
 9 Inflammation of the canal through which urine is discharged from the bladder.
 

VA Office of Inspector General 3 
Alleged Poor Quality of Care in Radiation Therapy, VA Long Beach Healthcare System, Long Beach, CA 

Patient 3 

Case Review. A patient underwent IMRT for prostate cancer during February—April 

2009. Approximately 1 month after initiation of hormone therapy in early September, an 

oncologist noted that although progression of the cancer had halted, the patient had 

developed diarrhea, dysuria, and urinary frequency. The patient continues to receive 

hormone therapy at the facility. 

Case Findings. We did not substantiate the allegation of inappropriate RT care. We 

found that treatment was appropriate and side effects anticipated. However, treatment 

documentation had discrepancies with respect to radiation doses and dates of treatment. 

Patient 4 

Case Review. A patient with oropharyngeal squamous cell cancer underwent a positron 

emission tomography scan that showed a large metabolically active pharyngeal mass. He 

had chemotherapy & concurrent IMRT to the head and neck area during 

March—May 2010. The patient experienced mucositis10 and mild erythema (redness) on 

the neck. During the course of treatment, the patient required blood transfusions. 

Case Findings. We did not substantiate the allegation of inappropriate RT care. We 

found that treatment was appropriate and side effects anticipated. However, there was no 

required treatment summary describing the patient’s response to IMRT or resolution of 

symptoms. 

Patient 5 

Case Review. A patient was diagnosed with low grade prostate cancer. He underwent 

IMRT treatment under research protocol during July—September 2009. The patient 

developed urinary frequency, nocturia, dysuria, and rectal irritation. During follow-up 

visits, side effects were noted to have subsided. 

Case Findings. We did not substantiate the allegation of inappropriate RT care. We 

found that treatment was appropriate and side effects anticipated. However, we found a 

change in the prescribed dose prior to initiation of treatment and noted the lack of 

documentation of this change and of the type of treatment delivered. 

Patient 6 

Case Review. A patient underwent IMRT for prostate cancer under research protocol 

during December—February 2010. Concerns after RT included a skin reaction in the 

10 Painful inflammation and ulceration of the mucous membranes lining the digestive tract. 

VA Office of Inspector General 4 
Alleged Poor Quality of Care in Radiation Therapy, VA Long Beach Healthcare System, Long Beach, CA 

buttocks area which improved during the course of treatment. The patient also 

experienced urinary frequency and dysuria which improved with medication 6 months 

after treatment. 

Case Findings. We did not substantiate the allegation of inappropriate RT care. We 

found that treatment was appropriate and side effects anticipated. However, the 

prescription was not complete, the isodose was not specified, and the treatment summary 

was not completed until eight weeks after treatment ended. We also noted that treatment 

progress notes written by RT residents were not co-signed by an attending physician as 

required by VHA policy.11 

Patient 7 

Case Review. A patient underwent IMRT under research protocol for prostate cancer 

during October—December 2009. A cystoscopy12 performed in July 2010 confirmed the 

diagnosis of radiation cystitis (inflammation of the urinary bladder). The patient had 

hematuria (blood in the urine) and required multiple visits to the Emergency Department 

for bladder irrigation. He did not require blood transfusion, but was treated with HBO 

and underwent 30 HBO treatments before the hematuria resolved. 

Case Findings. We did not substantiate the allegation of inappropriate RT care. We 

found that treatment was appropriate and side effects anticipated. However, we noted 

that the radiation oncologist changed the radiation prescription for the patient but did not 

document the change in the medical record.13 

Patient 8 

Case Review. A diabetic patient with a left above-the-knee amputation required longterm inpatient rehabilitation and wound care beginning in September 2008. In 

March 2009, he was diagnosed with anal margin squamous cell cancer and underwent 

surgery. RT was initiated in June 2009 and completed in August 2009. 

The patient experienced difficulty with urination which began after the 14th radiation 

treatment and continued until after the end of RT. In late August 2009, radiation cystitis 

was diagnosed and confirmed by cystoscopy. Treatment with HBO therapy was not 

indicated at that time. Residual bladder abnormalities were noted to be slowly improving 

as of March 2010. 

Case Findings. We did not substantiate the allegation of inappropriate RT care. We 

found that treatment was appropriate and side effects anticipated. However, follow-up 

11 VHA Handbook 1400.1, Resident Supervision, July 25, 2007.
 12 Examination of the urinary tract using a lighted instrument.
 13 American College of Radiology. ACR Practice Guideline for Radiation Oncology, Rev. 2009.
 

VA Office of Inspector General 5 
Alleged Poor Quality of Care in Radiation Therapy, VA Long Beach Healthcare System, Long Beach, CA 

evaluation of the patient was not completed within 4–6 weeks as required. Discrepancies 

were also found in the documentation of dates and type of treatment delivered. 

Patient 9 

Case Review. A patient with head and neck squamous cell cancer required RT and 

chemotherapy. The patient was admitted with open neck wounds and received the 

majority of his wound care, RT, and concurrent administration of cetuximab 

(chemotherapy) in the facility’s long-term care unit during June—August 2010. 

The neck wounds deteriorated soon after the sixth RT treatment, although it was not 

documented exactly when the worsening occurred. The patient was subsequently 

transferred to a private facility for treatment of bleeding arteries in the neck. The patient 

was transferred back to the facility and RT was resumed. 

Supportive wound care and intravenous antibiotics were later required for a neck wound 

infection. The right neck wounds healed and were considered superficial when the 

patient was discharged home in late September 2010, 3 months after initiation of RT. 

Case Findings. We did not substantiate the allegation of inappropriate RT care. The 

combination of cetuximab and RT was necessary in the management of this patient’s 

advanced malignancy. However, the combination imparted a high risk of skin 

complications. Facility staff reported that this case had been reviewed by an 

interdisciplinary team to determine the appropriateness of reporting to the U.S. Food and 

Drug Administration. The team concluded that reporting was not necessary for an 

expected reaction. 

Although we did not substantiate poor RT care, we found inadequate documentation of 

the patient’s response to treatment, including the status of neck lesions. In addition, the 

treatment summary was missing. 

Patient 10 

Case Review. A patient had metastatic non-small cell lung cancer unresponsive to 

chemotherapy provided at a private facility. The last dose of chemotherapy was given in 

June 2010. In July, the patient was found to have a large pericardial effusion, and a 

pericardial window was placed. 

The patient was transferred to the facility in mid-July 2010 for RT. He was seen by the 

radiation oncologist on the day of admission, but treatment was not initiated because the 

patient was unable to lie flat. The plan was to initiate second-line chemotherapy, with 

RT to be attempted again if and when appropriate. Chemotherapy infusions were 

initiated but stopped due to the patient’s shortness of breath. RT was never contacted 

VA Office of Inspector General 6 
Alleged Poor Quality of Care in Radiation Therapy, VA Long Beach Healthcare System, Long Beach, CA 

again for re-evaluation. The patient’s condition continued to deteriorate, and he expired 

in mid-August 2010 after electing palliative (end-of-life) care. 

Case Findings. We did not substantiate the allegation of inappropriate RT care. The 

patient had very advanced disease and could not tolerate the positioning requirements for 

RT. There was no further request for RT, and the patient expired after choosing 

palliative care. 

Issue 2: Communication with Facility Leadership

We substantiated the allegation that senior leaders were not aware of RT patient 

outcomes. VHA expects that “peer review done for quality management fosters a 

responsive environment where issues are identified, acted upon proactively, and in ways 

that continually contribute to the best possible outcomes and strong organizational 

performance”.14 Facility staff confirmed that RT peer reviews had been performed. 

However, results had not been communicated to facility leadership nor was action taken 

to correct deficiencies identified in peer reviews. 

During our onsite visit, facility staff provided evidence of plans for a new “Radiation 

Therapy and Oncology Quality Management Committee” which would focus on clinical 

care monitors such as unplanned interruptions during treatment, unusual, severe, early, or 

late complications of treatment, and unexpected deaths during RT care. The committee is 

to meet quarterly and report to the Medical Executive Council. Staff also provided a 

2010 charter for a Comprehensive Cancer Program which is expected to work in concert 

with the committee and assume responsibility for the “continuous overview of the quality 

of cancer care, evaluate its safety and long-term results, and assure timely reporting to the 

[facility] Executive Leadership Board”. 

Conclusions

We substantiated the allegation of poor care for 1 of the 10 patients reported and found 

deficiencies in the medical record documentation for 9 of the 10 patients. We also 

substantiated that facility leaders were not aware of patient outcomes in RT nor was 

action taken to correct deficiencies identified in peer reviews. 

We did not substantiate the allegation that radiation oncologists lacked competence. The 

C&P folders and profiles of the radiation oncologists complied with VHA policy. Peer 

reviews for ongoing professional practice evaluations were appropriately documented. 

14 VHA Directive 2010-025, Peer Review for Quality Management, June 3, 2010. 

VA Office of Inspector General 7 
Alleged Poor Quality of Care in Radiation Therapy, VA Long Beach Healthcare System, Long Beach, CA 

Recommendations

Recommendation 1. We recommend that the VISN Director require that the Facility 

Director ensures that an external peer review assessment of the treatment provided by 

radiation oncologists for Patient 1 is performed. 

Recommendation 2. We recommend that the VISN Director require that the Facility 

Director evaluates the care of Patient 1 with Regional Counsel for possible disclosure to 

the patient. 

Recommendation 3. We recommend that the VISN Director require that the Facility 

Director ensures that RT medical record documentation complies with VHA policy and 

ACR guidelines. 

Recommendation 4. We recommend that the VISN Director require that the Facility 

Director ensures that RT patient outcomes are monitored by the Quality Management 

program and others external to the RT department to oversee the implementation of 

corrective actions for all adverse patient outcomes. 

Comments

The VISN and facility Directors agreed with our findings and recommendations. The 

implementation plans are acceptable, and we will follow up on the planned actions until 

they are completed. 

 (original signed by:)

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

Assistant Inspector General for
 

Healthcare Inspections
 

VA Office of Inspector General 8 
Alleged Poor Quality of Care in Radiation Therapy, VA Long Beach Healthcare System, Long Beach, CA 

Appendix A

VISN Director Comments
 

Department of

Veterans Affairs Memorandum

Date:	 February 14, 2011 

From:	 Director, Veterans Integrated Service Network 22 

Subject:	 Healthcare Inspection – Alleged Radiation Therapy Quality of Care 

Issues, VA Long Beach Healthcare System, Long Beach, CA 

To:	 Associate Director, Los Angeles Regional Office of Healthcare 

Inspections (54LA) 

Thru:	 Director, Management Review Service (10B5) 

1. VISN 22 is in concurrence with VA Long Beach Medical 

Center Director’s comments to the four recommendations. 

2. If you should have any questions, please contact VISN 22 

Quality Management Officer, Kathy Bucher, at 562-826-

5963. 

(original signed by:) 

Barbara Fallen,
 

Acting Network Director
 

VA Office of Inspector General 9 
Alleged Poor Quality of Care in Radiation Therapy, VA Long Beach Healthcare System, Long Beach, CA 

Department of

Veterans Affairs Memorandum

Date:	 February 14, 2011 

From:	 Director, VA Long Beach Healthcare System (600/00) 

Subject:	 Healthcare Inspection – Alleged Radiation Therapy Quality of Care 

Issues, VA Long Beach Healthcare System, Long Beach, CA 

To:	 Associate Director, Los Angeles Regional Office of Healthcare 

Inspections (54LA) 

1. Attached is the response to the Long Beach Hotline Draft 

Report, Alleged Poor Quality of Care in Radiation 

Therapy. We have provided a narrative to the four 

recommendations in the Office of Inspector General’s 

(OIG) report. 

2. If you have questions or require additional information, 

please contact Nancy Downey, Quality Manager, at (562) 

826-5249. 

(original signed by:) 

Isabel Duff, MS 

Director 

Attachment 

VA Office of Inspector General 10 
Alleged Poor Quality of Care in Radiation Therapy, VA Long Beach Healthcare System, Long Beach, CA 

Director’s Comments
 

to Office of Inspector General’s Report
 

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

recommendation in the Office of Inspector General’s report. 

OIG Recommendation 

Recommendation 1. We recommend that the VISN Director require that 

the Facility Director ensures that an external peer review assessment of the 

treatment provided by radiation oncologists for Patient 1 is performed. 

Concur Target Completion Date: February 4, 2011 

Facility’s Response: 

On Friday, February 4, 2011, the Facility’s Risk Manager submitted a 

request to VISN 22 for an external peer review to be conducted by 

Lumetra, the VA contractor for external peer reviews. In the event 

Lumetra’s services are unavailable, the case will be referred to the 

Radiation Therapy Service at VA Greater Los Angeles Healthcare System. 

Upon completion, the findings of the external peer review will be discussed 

by the Protected Peer Review Committee and action recommended to the 

appropriate entities, including the Facility Director. 

Status: Closed 

Recommendation 2. We recommend that the VISN Director require that 

the Facility Director evaluates the care of Patient 1 with Regional Counsel 

for possible disclosure to the patient. 

Concur Target Completion Date: February 7, 2011 

Facility’s Response: 

On Monday, February 7, 2011, the case was referred to Regional Counsel 

for review. The determination of disclosure will be made by the Facility 

Director in consultation with Regional Counsel after completion of the 

external peer review. 

VA Office of Inspector General 11 
Alleged Poor Quality of Care in Radiation Therapy, VA Long Beach Healthcare System, Long Beach, CA 

Status: Closed 

Recommendation 3. We recommend that the VISN Director require that 

the Facility Director ensures that RT medical record documentation 

complies with VHA policy and ACR guidelines. 

Concur Target Completion Date: August 18, 2011 

Facility’s Response: 

The Radiation Therapy Quality Management Committee developed and 

implemented a Clinical Quality Plan detailing quality assurance and 

oversight activities for the Radiation Therapy Service. The action plan 

includes documentation improvement and monitoring. Specifically, it 

addresses the ongoing review of medical record documentation to ensure 

compliance with the VHA and ACR guidelines. The Radiation Therapy 

Nurse audits the medical records daily to ensure progress notes, treatment 

summaries, radiation doses, and treatment modifications are completed 

within 7 days after the last radiation therapy treatment. Documentation 

discrepancies are addressed in the weekly chart round meetings. The 

Radiation Therapy Chief reports medical record quality assurance 

aggregate data to the Radiation Therapy Quality Management Committee 

on a monthly basis and will continue to do so until 95% documentation 

compliance is sustained for a period of 6 months. 

Status: Open 

Recommendation 4. We recommend that the VISN Director require that 

the Facility Director ensures that Radiation Therapy (RT) patient outcomes 

are monitored by the Quality Management program and others external to 

the RT department to oversee the implementation of corrective actions for 

all adverse patient outcomes. 

Concur Target Completion Date: August 18, 2011 

Facility’s Response: 

Patient outcomes related to the delivery of radiation therapy are collected 

using clinical monitors. The Radiation Therapy Quality Management 

Committee provides a summary of all adverse clinical outcomes, which 

include, but are not limited to, skin breakdown, hematuria/radiation cystitis, 

and unexpected treatment interruptions, to the Medical Executive 

VA Office of Inspector General 12 
Alleged Poor Quality of Care in Radiation Therapy, VA Long Beach Healthcare System, Long Beach, CA 

Committee quarterly. The report includes an analysis and summary of 

clinical monitors, unexpected complications, and adverse outcomes. This 

report, further assessment and recommendations are also reported to 

Executive Leadership & Quality Board (chaired by the Medical Center 

Director), where this information is further reviewed, and analyzed 

quarterly. To further ensure patient safety and quality of care, a corrective 

action plan is required within 10 days for all deficiencies identified. The 

Radiation Therapy Administrative Officer (currently an Acting is in place) 

ensures timely completion of the corrective actions. The Chief of 

Diagnostic & Molecular Medicine Healthcare Group reviews outcome data 

quarterly, and will implement Focused Professional Practice Evaluation 

when there is a concern regarding a practitioner’s ability to provide safe, 

high quality patient care. 

Status: Open 

VA Office of Inspector General 13 
Alleged Poor Quality of Care in Radiation Therapy, VA Long Beach Healthcare System, Long Beach, CA 

Appendix B

OIG Contact and Staff Acknowledgments
 

OIG Contact Mary Toy, RN, Associate Director 

Los Angeles Regional Office of Healthcare Inspections 

Jerome Herbers, MD 

Simonette Reyes, RN 

VA Office of Inspector General 14 
Alleged Poor Quality of Care in Radiation Therapy, VA Long Beach Healthcare System, Long Beach, CA 

Appendix C

Report Distribution
 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, Veterans Integrated Service Network 22 (10N22) 

Director, VA Long Beach Healthcare System (600/00) 

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: Barbara Boxer, Dianne Feinstein 

U.S. House of Representatives: John Campbell, Judy Chu, Jane Harman, Gary Miller, 

Grace Napolitano, Laura Richardson, Dana Rohrabacher, Lucille Roybal-Allard, 

Edward Royce, Linda Sanchez, Loretta Sanchez, Adam Schiff, Maxine Waters, Henry 

Waxman 

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

VA Office of Inspector General 15