Department of Veterans Affairs 

Office of Inspector General 

Office of Healthcare Inspections
	

Report No. 11-00841-122 

Community Based Outpatient
	

Clinic Reviews
	

Stamford and Waterbury, CT
	

North Charleston (Goose Creek), SC
	

and Savannah, GA
	

Nephi, UT and Pocatello, ID
	

March 16, 2011
	

Washington, DC 20420
	
Why We Did This Review 

The VA Office of Inspector General (OIG) is undertaking a systematic review of

the Veterans Health Administration’s (VHA’s) community-based outpatient clinics

(CBOCs) to assess whether CBOCs are operated in a manner that provides

veterans with consistent, safe, high-quality health care.

The Veterans’ Health Care Eligibility Reform Act of 1996 was enacted to equip

VA with ways to provide veterans with medically needed care in a more

equitable and cost-effective manner. As a result, VHA expanded the

Ambulatory and Primary Care Services to include CBOCs located throughout the

United States. CBOCs were established to provide more convenient access to

care for currently enrolled users and to improve access opportunities within

existing resources for eligible veterans not currently served.

Veterans are required to receive one standard of care at all VHA health care

facilities. Care at CBOCs needs to be consistent, safe, and of high quality,

regardless of model (VA-staffed or contract). CBOCs are expected to comply

with all relevant VA policies and procedures, including those related to quality,

patient safety, and performance.

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) 
Stamford, Waterbury, Goose Creek, Savannah, Nephi, and Pocatello

Glossary 

A1c glycated hemoglobin

C&P credentialing and privileging

CBOC community based outpatient clinic

COTR Contracting Officer’s Technical Representative

CVMC Central Valley Medical Center

DM Diabetes Mellitus

EKG electrocardiogram

EOC environment of care

FY fiscal year

FTE full-time employee equivalents

HCS Health Care System

IC infection control

LCSW Licensed Clinical Social Worker

LPN Licensed Practical Nurse

MH mental health

MST military sexual trauma

NFPA National Fire Protection Association

NP nurse practitioner

OEF/OIF Operation Enduring Freedom/Operation Iraqi

Freedom

OIG Office of Inspector General

OPPE Ongoing Professional Practice Evaluation

PA physician assistant

PCMM Primary Care Management Model

PCP primary care provider

PTSD Post-Traumatic Stress Disorder

Qtr quarter

RN registered nurse

SSN social security number

SOP standard operating procedure

VAMC VA Medical Center

VHA Veterans Health Administration

VISN Veterans Integrated Service Network

VA OIG Office of Healthcare Inspections
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Stamford, Waterbury, Goose Creek, Savannah, Nephi, and Pocatello

Table of Contents
	

Page 

Executive Summary ...................................................................................................

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

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

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

Results and Recommendations................................................................................ 3

VISN 1, VA Connecticut HCS – Stamford and Waterbury ...................................... 3

VISN 7, Ralph H. Johnson VAMC – Goose Creek and Savannah.......................... 8

VISN 19, VA Salt Lake City HCS – Nephi and Pocatello ........................................ 12

Appendixes 

A. VISN 1 Director Comments ............................................................................... 20

B. VA Connecticut HCS Acting Director Comments............................................... 21

C. VISN 7 Acting Director Comments .................................................................... 23

D. Ralph H. Johnson VAMC Director Comments................................................... 24

E. VISN 19 Director Comments ............................................................................. 26

F. VA Salt Lake City HCS Director Comments ...................................................... 27

G. OIG Contact and Staff Acknowledgments ......................................................... 31

H. Report Distribution............................................................................................. 32

VA OIG Office of Healthcare Inspections
Stamford, Waterbury, Goose Creek, Savannah, Nephi, and Pocatello

Executive Summary
	

Purpose: We conducted the review of six CBOCs during the weeks of

December 6, 2010. CBOCs were reviewed in VISN 1 at Stamford and Waterbury, CT;

in VISN 7 at North Charleston (Goose Creek), SC, and Savannah, GA; and, in VISN 19

at Nephi, UT and Pocatello, ID. The parent facilities of these CBOCs are

VA Connecticut HCS, Ralph H. Johnson VAMC, and VA Salt Lake City HCS,

respectively. The purpose was to evaluate selected activities, assessing whether the

CBOCs are operated in a manner that provides veterans with consistent, safe, highquality health care.

Recommendations: The VISN and Facility Directors, in conjunction with the

respective CBOC manager, should take appropriate actions to:

VA Connecticut HCS

	 Ensure facility managers fully implement the improvement plan to communicate

normal test results at the Stamford and Waterbury CBOCs.

	 Conduct monthly visual inspections of all portable fire extinguishers at the Waterbury

CBOC.

Ralph H. Johnson VAMC

	 Align exit signage to identify the correct pathway of egress at the Goose Creek

CBOC.

VA Salt Lake City HCS

	 Require that provider privileges are consistent with the services provided at the

Pocatello CBOC.

	 Require that ordering providers document patient notification and treatment actions

in response to critical laboratory test results at the Pocatello CBOC.

	 Ensure that the Contracting Officer makes provisions to award contracts within a

timeframe in accordance with VA policies, procedures, and directives to avoid the

need for sole source emergency purchase orders at the Nephi CBOC.

	 Assess the collectability of $119,000 in overpayments to the vendor with the

assistance of the Regional Counsel.

	 Initiate the necessary contract modifications for the satellite clinic.

	 Ensure the contract provision includes a prorated reduction of an annual capitated

rate payment for services provided less than 12 months.

VA OIG Office of Healthcare Inspections i 
Stamford, Waterbury, Goose Creek, Savannah, Nephi, and Pocatello

Comments 

The VISN and facility Directors agreed with the CBOC review findings and

recommendations and provided acceptable improvement plans. (See Appendixes A–F,

pages 20–30 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 Inspections
 

VA OIG Office of Healthcare Inspections ii
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Stamford, Waterbury, Goose Creek, Savannah, Nephi, and Pocatello

Part I. Objectives and Scope 

Objectives. The purposes of this review are to:

 Determine whether CBOC performance measure scores are comparable to the

parent VAMC or HCS outpatient clinics.

 Determine whether CBOC providers are appropriately credentialed and privileged in

accordance to VHA Handbook 1100.19.1

 Determine whether appropriate notification and follow-up action are documented in

the medical record when critical laboratory test results are generated.

 Determine the extent patients are notified of normal laboratory test results.

 Determine whether CBOCs are in compliance with standards of operations

according to VHA Handbook 1006.12 in the areas of environmental safety and

emergency planning.

 Determine whether the CBOC primary care and mental health contracts were

administered in accordance with contract terms and conditions.

 Determine whether primary care active panel management and reporting are in

compliance with VHA Handbook 1101.02.3

Scope. The topics discussed in this report include:

 Quality of Care Measures

 C P

 Management of Laboratory Results

 EOC and Emergency Management

 CBOC Contracts

We formulated a list of CBOC characteristics and developed an online survey for data

collection. The surveys were completed by the respective CBOC managers. The

characteristics included identifiers and descriptive information for CBOC evaluation.

We reviewed CBOC policies, performance documents, provider C P files, and nurses’

personnel records. For each CBOC, we evaluated the quality of care measures by

reviewing 50 randomly selected patients with a diagnosis of DM and 30 female patients

between the ages of 52 and 69 years of age who had mammograms, unless fewer

patients were available. We reviewed the medical records of these selected patients to

1 VHA Handbook 1100.19, Credentialing and Privileging, November 14, 2008.
 2 VHA Handbook 1006.1, Planning and Activating Community-Based Outpatient Clinics, May 19, 2004.
 3 VHA Handbook 1101.02, Primary Care Management Module (PCMM), April 21, 2009.
 

VA OIG Office of Healthcare Inspections 1
Stamford, Waterbury, Goose Creek, Savannah, Nephi, and Pocatello

determine compliance with VHA performance measures.

We also reviewed medical records for 10 patients who had critical laboratory results and

10 patients with normal laboratory results or fewer if 10 were not available. We used

the term critical value or result as defined in VHA Directive 2009-019.4 A critical test

result is defined as those values or interpretations that, if left untreated, could be life

threatening or place the patient at serious risk. All emergent test results and some

abnormal test results constitute critical values or results. Although not defined in the

directive, we used the term normal results to describe test or procedure results that are

neither emergent nor abnormal, or results that are within or marginally outside the

expected or therapeutic range.

We conducted EOC inspections to determine the CBOCs’ cleanliness and condition of

the patient care areas, condition of equipment, adherence to clinical standards for IC

and patient safety, and compliance with patient data security requirements. We

evaluated whether the CBOCs had a local policy/guideline defining how health

emergencies, including MH emergencies, are handled.

We evaluated whether the Nephi CBOC contract provided guidelines that the contractor

needed to follow in order to address quality of care issues. We also verified that the

number of enrollees or visits reported was supported by collaborating documentation.

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.

4 VHA Directive 2009-019, Ordering and Reporting Test Results, March 24, 2009. 

VA OIG Office of Healthcare Inspections 2
Stamford, Waterbury, Goose Creek, Savannah, Nephi, and Pocatello

Part II. Results and Recommendations 

A. VISN 1, VA Connecticut HCS – Stamford and Waterbury 

CBOC Characteristics 

Table 1 shows the characteristics of the Stamford and Waterbury CBOCs.

CBOC Characteristics Stamford Waterbury 

Type of CBOC VA Staffed VA Staffed

Number of Uniques, FY 2010 1,885 2,609

Number of Visits, FY 2010 3,981 6,669

CBOC Size5 Mid-Size Mid-Size

Locality Urban Urban

FTE 2 1.6

Type Providers Assigned Internal Medicine

Physician

PCP

Psychiatrist

Psychologist

Internal Medicine

Physician

PCP

NP

Psychiatrist

Psychologist

Ancillary Staff Assigned RN

Health/Medical

Technician or Assistant

RN

Pharmacist

Health/Medical

Technician or Assistant

Type of MH Providers Psychologist

Psychiatrist

Psychologist

Psychiatrist

Provides MH Services Yes Yes

 Evening Hours No No

 Weekends No No

 Plan for Emergencies 

Outside of Business Hours 

No No

 Provided Onsite PTSD

General MH Homelessness

 Referrals Another VA facility Another VA facility

 Tele-Mental Health Services 

Yes (Medication

management,

individual therapy, and

pain management)

No

Specialty Care Services Onsite No No

 Referrals Another VA facility

Non-VA fee-basis or

contract

Another VA facility

Non-VA fee-basis or

contract

Ancillary Services Provided Onsite EKG EKG

Miles to Parent Facility 38 27

Table 1. CBOC Characteristics 

5 Based on the number of unique patients seen as defined by the VHA Handbook 1160.01. 

VA OIG Office of Healthcare Inspections 3
 

 

Stamford, Waterbury, Goose Creek, Savannah, Nephi, and Pocatello

Quality of Care Measures6 

DM

Diabetes is the leading cause of new cases of blindness among adults age 20−74 and 

diabetic retinopathy causes 12,000 to 24,000 new cases of blindness each year.

Detection and treatment of diabetic eye disease with laser therapy can reduce the

development of severe vision loss by an estimated 50−60 percent. Table 2 displays 

the parent facility and the Stamford and Waterbury CBOCs’ compliance in screening

for retinopathy.

Measure 

Meets 

Target Facility 

Qtr 3 

Numerator 

Qtr 3 

Denominator 

Qtr 3 

(%) 

DM – Retinal Eye 

Exam 

70% 689 VA Connecticut HCS 44 48 91 

689GB Stamford CBOC 8 8 100 

689GA Waterbury CBOC 10 11 91 

Table 2. Retinal Exam, FY 2010 

A1c is a blood test that measures average blood glucose (sugar) levels. Research

studies in the United States and abroad have found that improved glycemic control

benefits people with either type I or type II diabetes. In general, for every 1 percent

reduction in A1c, the relative risk of developing microvascular diabetic complications

(eye, kidney, and nerve disease) is reduced by 40 percent. The American Diabetes

Association recommends an A1c of less than 7 percent. Patients with poorly

controlled diabetes (A1c greater than 9 percent) are at higher risk of developing

diabetic complications. Measuring A1c assesses the effectiveness of therapy. For this

indicator, low scores indicate better compliance. Table 3 displays the scores of the

parent facility and the Stamford and Waterbury CBOCs.

Measure 

Meets 

Target Facility 

Qtr 3 

Numerator 

Qtr 3 

Denominator 

Qtr 3 

(%) 

DM –A1c > 9 or not 

done in past year 

16% 689 VA Connecticut HCS 11 48 32 

689GB Stamford CBOC 0 8 0 

689GA Waterbury CBOC 0 11 0 

Table 3. A1c Testing, FY 2010 

6 Parent facility scores were obtained from http://vaww.pdw.med.va.gov/MeasureMaster/MMReport.asp Note: 

Scores are weighted. The purpose of weighting is to correct for the over-representation of cases from small sites and 

the under-representation of cases from large sites. It corrects for the unequal number of available cases within each 

organizational level (i.e., CBOC, facility) and protects against the calculation of biased or inaccurate scores. 

Weighting can alter the raw measure score (numerator/denominator). Raw scores can go up or down depending on 

which cases pass or fail a measure. Sometimes the adjustment can be quite significant. 

VA OIG Office of Healthcare Inspections 4
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Stamford, Waterbury, Goose Creek, Savannah, Nephi, and Pocatello

Women’s Health

Breast cancer is the second most common type of cancer among American women,

with approximately 207,000 new cases reported each year.7 It is most common in

women over 50. Women whose breast cancer is detected early have more treatment

choices and better chances for survival. Screening by mammography (an x-ray of the

breast) has been shown to reduce mortality by 20–30 percent among women 40 and

older. The patients at the Stamford CBOC did not meet the criteria for our review;

therefore, we were unable to compare this CBOC to the parent facility. Comparison of

the Waterbury CBOC to the parent facility’s breast cancer screening is listed in

Table 4.

Measure 

Meets 

Target Facility 

Qtr 3 

Numerator 

Qtr 3 

Denominator 

Qtr 3 

(%) 

Mammography, 

50-69 years old 

77% 689 VA Connecticut HCS 18 26 63 

689GB Stamford CBOC NA NA NA 

689GA Waterbury CBOC 8 11 73 

Table 4. Women’s Health, FY 2010 

Three of the 11 patient records reviewed did not have mammography reports within

the study period. Although the Waterbury CBOC did not meet the target score of

77 percent, we found documentation that CBOC managers attempted to provide the

mammography service for two of the three patients. One patient rescheduled and

completed the mammography after the study period,8 and the other patient declined

the mammography. Therefore, we did not request an action plan to improve the

measure score.

C&P 

We reviewed the C P files of five providers and the personnel folder of one nurse at

the Stamford CBOC and five providers and one nurse at the Waterbury CBOC. All

providers possessed full, active, current, and unrestricted licenses; and privileges were

appropriate for services rendered. All nurses’ license and education requirements

were verified and documented. Service-specific criteria for OPPE had been developed

and approved. We found sufficient performance data to meet current requirements.

Management of Laboratory Results 

VHA Directive 2009-019 requires critical test results to be communicated to the

ordering provider or surrogate provider within a timeframe that allows for prompt

attention and appropriate clinical action to be taken. VHA also requires that the

ordering provider communicate test results to patients so that they may participate in

health care decisions. Each parent facility is required to develop a written policy for

7 American Cancer Society, Cancer Facts & Figures 2009. 

8 The study period is April 1, 2008, through June 30, 2010. 

VA OIG Office of Healthcare Inspections 5
Stamford, Waterbury, Goose Creek, Savannah, Nephi, and Pocatello

communicating test results to providers and documenting communications in the

medical record, to include a system for surrogate providers to receive results when the

ordering provider is not available. In addition, ordering providers are required to

communicate outpatient test results (those not requiring immediate attention) to

patients no later than 14 calendar days from the date on which the results are

available to the ordering provider.

We reviewed the parent facility’s policies and procedures and the medical records of

patients who had tests resulting in critical values and normal values. We determined

that the facility had developed a written policy and had implemented a reporting

process for test results.

Critical Laboratory Results

We found that the Stamford and Waterbury CBOCs had effective processes in place to

communicate critical laboratory test results to ordering providers and patients. We

reviewed the medical records of 8 patients (5 at the Stamford CBOC and 3 at the

Waterbury CBOC) who had critical laboratory results and found that all records

contained documented evidence of patient notification and follow-up actions.

Normal Laboratory Results

We reviewed the medical records of 20 patients (10 at the Stamford CBOC and 10 at

the Waterbury CBOC) who had normal test results. We found documentation that

providers communicated the normal results to 7 (70 percent) patients at the Stamford

CBOC and 4 (40 percent) at the Waterbury CBOC, within 14 calendar days from the

date the results were available to the ordering provider.

Recommendation 1: We recommended that facility managers fully implement a plan

for improvement in communication of normal test results to patients at the Stamford

and Waterbury CBOCs and monitor compliance.

Environment and Emergency Management 

EOC

To evaluate the EOC, we inspected patient care areas for cleanliness, safety, IC, and

general maintenance. Both CBOCs met most standards, and the environments were

generally clean and safe. We found that the IC program monitored data and

appropriately reported data to relevant committees. Safety guidelines were generally

met, and risk assessments were in compliance with VHA standards. However, one

area at the Waterbury CBOC needed improvement.

VA OIG Office of Healthcare Inspections 6
Stamford, Waterbury, Goose Creek, Savannah, Nephi, and Pocatello

Fire Extinguishers

We found that two of three portable fire extinguishers did not have monthly visual

inspections. NFPA Code 109 requires that fire extinguishers be inspected monthly.

Routine visual inspections help to ensure that extinguishers are accessible and that

the pressure gauge indicator is in the operable range, indicating that the fire

suppressant is sufficiently pressurized for use in the event of a fire.

Recommendation 2: We recommended that managers require monthly visual

inspections of all portable fire extinguishers at the Waterbury CBOC.

Emergency Management

VHA Handbook 1006.1 requires each CBOC to have a local policy or SOP defining

how medical emergencies, including MH emergencies, are handled. Both CBOCs had

policies that outlined management of medical and MH emergencies, and staff

articulated responses that accurately reflected local emergency response guidelines.

9 NFPA, Code 10, Chapter 7, 2010 Edition. 

VA OIG Office of Healthcare Inspections 7
Stamford, Waterbury, Goose Creek, Savannah, Nephi, and Pocatello

B. VISN 7, Ralph H. Johnson VAMC – Goose Creek and Savannah 

CBOC Characteristics 

Table 5 shows the characteristics of the Goose Creek and Savannah CBOCs.

CBOC Characteristics Goose Creek Savannah 

Type of CBOC VA Staffed VA Staffed

Number of Uniques, FY 2010 8,742 10,430

Number of Visits, FY 2010 52,713 64,967

CBOC Size Large Very Large

Locality Urban Rural

FTE 8.5 9.9

Type Providers Assigned PCP

NP

Psychiatrist

LCSW

Internal Medicine Physician

PCP

NP

PA

Psychiatrist

Psychologist

LCSW

Ancillary Staff Assigned RN

LPN

Pharmacist

Technician/Technologists

Health/Medical

Technician or Assistant

RN

LPN

Pharmacist

Technician/Technologists

Health/Medical

Technician or Assistant

Type of MH Providers Psychiatrist

NP/Clinical Nurse Specialist

LCSW

Psychologist

Psychiatrist

PA

NP/Clinical Nurse Specialist

LCSW

Provides MH Services Yes Yes

 Evening Hours No No

 Weekends No Yes

 Plan for Emergencies 

Outside of Business Hours 

No No

 Provided Onsite PTSD

OEF/OIF Groups

Substance Use Disorder

PTSD

MST

Homelessness

General MH Counseling

MH Intensive Case

Management

 Referrals Another VA facility Another VA facility

Non-VA fee-basis or contract

 Tele-Mental Health Services No Yes (Medication

Management and Individual

Therapy)

Remote Services Tele-Retinal Tele-Medicine

Tele-Radiology

VA OIG Office of Healthcare Inspections 8
 

 

Stamford, Waterbury, Goose Creek, Savannah, Nephi, and Pocatello

CBOC Characteristics (con’d) 

Specialty Care Services Onsite 

Goose Creek 

No

Savannah 

Yes

 Type NA Optometry

Podiatry

Women’s Health

 Referrals Another VA facility Another VA facility

Ancillary Services Provided Onsite Laboratory (blood drawn

onsite)

Physical Medicine

Radiology

EKG

Miles to Parent Facility 18 116

Table 5. CBOC Characteristics 

Quality of Care Measures 

DM

Diabetes is the leading cause of new cases of blindness among adults age 20−74 and 

diabetic retinopathy causes 12,000 to 24,000 new cases of blindness each year.

Detection and treatment of diabetic eye disease with laser therapy can reduce the

development of severe vision loss by an estimated 50−60 percent. Table 6 displays the 

parent facility and the Goose Creek and Savannah CBOCs’ compliance in screening for

retinopathy.

Measure 

Meets 

Target Facility 

Qtr 3 

Numerator 

Qtr 3 

Denominator 

Qtr 3 

(%) 

DM – Retinal Eye 

Exam 

70% 534 Ralph H. Johnson VAMC 54 66 83 

534GD Goose Creek CBOC 46 49 94 

534BY Savannah CBOC 44 48 92 

Table 6. Retinal Exam, FY 2010 

A1c is a blood test that measures average blood glucose (sugar) levels. Research

studies in the United States and abroad have found that improved glycemic control

benefits people with either type I or type II diabetes. In general, for every 1 percent

reduction in A1c, the relative risk of developing microvascular diabetic complications

(eye, kidney, and nerve disease) is reduced by 40 percent. The American Diabetes

Association recommends an A1c of less than 7 percent. Patients with poorly controlled

diabetes (A1c greater than 9 percent) are at higher risk of developing diabetic

complications. Measuring A1c assesses the effectiveness of therapy. For this

indicator, low scores indicate better compliance. Table 7 displays the scores of the

parent facility and the Goose Creek and Savannah CBOCs.

Measure 

Meets 

Target Facility 

Qtr3 

Numerator 

Qtr 3 

Denominator 

Qtr 3 

(%) 

DM –A1c > 9 or not 

done in past year 

22% 534 Ralph H. Johnson VAMC 13 66 19 

534GD Goose Creek CBOC 13 49 27 

534BY Savannah CBOC 10 48 21 

Table 7. A1c Testing, FY 2010 

VA OIG Office of Healthcare Inspections 9
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Stamford, Waterbury, Goose Creek, Savannah, Nephi, and Pocatello

To improve compliance, managers have assigned staff to complete concurrent medical

record reviews and notify providers of variances. This process allows providers the

opportunity to adjust their treatment plans during the patient’s encounter.

Women’s Health

Breast cancer is the second most common type of cancer among American women,

with approximately 207,000 new cases reported each year. It is most common in

women over 50. Women whose breast cancer is detected early have more treatment

choices and better chances for survival. Screening by mammography (an x-ray of the

breast) has been shown to reduce mortality by 20–30 percent among women 40 and

older. Comparison of the Goose Creek and Savannah CBOCs to the parent facility’s

breast cancer screening compliance is listed in Table 8.

Measure 

Meets 

Target Facility 

Qtr 3 

Numerator 

Qtr 3 

Denominator 

Qtr 3 

(%) 

Mammography, 

50-69 years old 

77% 534 Ralph H. Johnson VAMC 11 11 100 

534GD Goose Creek CBOC 29 30 97 

534BY Savannah CBOC 21 26 81 

Table 8. Women’s Health, FY 2010 

C&P 

We reviewed the C P files of five providers and the personnel folders of four nurses at

the Goose Creek CBOC and five providers and four nurses at the Savannah CBOC. All

providers possessed a full, active, current, and unrestricted license; and privileges were

appropriate for services rendered. All nurses’ license and education requirements were

verified and documented. Service-specific criteria for OPPE had been developed and

approved. We found sufficient performance data to meet current requirements. OPPE

included competency criteria for privileges.

Management of Laboratory Results 

VHA Directive 2009-019 requires critical test results to be communicated to the ordering

provider or surrogate provider within a timeframe that allows for prompt attention and

appropriate clinical action to be taken. VHA also requires that the ordering provider

communicate test results to patients so that they may participate in health care

decisions. Each parent facility is required to develop a written policy for communicating

test results to providers and documenting communications in the medical record, to

include a system for surrogate providers to receive results when the ordering provider is

not available. In addition, ordering providers are required to communicate outpatient

test results (those not requiring immediate attention) to patients no later than

14 calendar days from the date on which the results are available to the ordering

provider.

We reviewed the parent facility’s policies and procedures and the medical records of

patients who had tests resulting in critical values and normal values. We determined

VA OIG Office of Healthcare Inspections 10
Stamford, Waterbury, Goose Creek, Savannah, Nephi, and Pocatello

that the facility had developed a written policy and had implemented an effective

reporting process for test results.

Critical Laboratory Results

We found that the Goose Creek and Savannah CBOCs had effective processes in

place to communicate critical laboratory test results to ordering providers and patients.

We reviewed the medical records of 20 patients (10 at the Goose Creek CBOC and

10 at the Savannah CBOC) who had critical laboratory results and found that all records

contained documented evidence of patient notification and follow-up actions.

Normal Laboratory Results

We found that the Goose Creek and Savannah CBOCs had effective processes in

place to communicate normal laboratory test results to patients. We reviewed the

medical records of 20 patients (10 at the Goose Creek CBOC and 10 at the Savannah

CBOC) and determined that the CBOCs had communicated normal results to all

patients within 14 calendar days from the date the results were available to the ordering

provider.

Environment and Emergency Management 

EOC

To evaluate the EOC, we inspected patient care areas for cleanliness, safety, IC, and

general maintenance. Both CBOCs met most standards, and the environments were

generally clean and safe. We found that the IC program monitored data and

appropriately reported that data to relevant committees. Safety guidelines were

generally met, and risk assessments were in compliance with VHA standards. We

found the following area needed improvements.

Fire Exit Signage

The escape pathway to a designated means of egress was not readily apparent at the

Goose Creek CBOC. Signage throughout the CBOC led to mistaken means of egress.

The NFPA10 requires that means of egress be obvious and directional to ensure safety.

Recommendation 3: We recommended that exit signage be aligned to identify the

correct pathway of egress at the Goose Creek CBOC.

Emergency Management

VHA Handbook 1006.1 requires each CBOC to have a local policy or SOP defining how

medical and MH emergencies are handled. Both CBOCs had policies that outlined

management of medical and MH emergencies, and staff at each facility articulated

responses that accurately reflected the local emergency response guidelines.

10 NFPA, Standard 101 Safety Code, 2009 edition. 

VA OIG Office of Healthcare Inspections 11
Stamford, Waterbury, Goose Creek, Savannah, Nephi, and Pocatello

C. VISN 19, VA Salt Lake City HCS – Nephi and Pocatello 

CBOC Characteristics 

Table 9 shows the characteristics of the Nephi and Pocatello CBOCs.

CBOC Characteristics Nephi Pocatello 

Type of CBOC Contract VA Staffed

Number of Uniques, FY 2010 699 4,799

Number of Visits, FY 2010 1,353 23,948

CBOC Size Small Mid-Size

Locality Highly Rural Urban

FTE 0.45 4.6

Type Providers Assigned NP Internal Medicine Physician

PCP

NP

PA

Psychiatrist

Psychologist

LCSW

Ancillary Staff Assigned Patient Service Assistant RN

LPN

Pharmacist

Health/Medical

Technician or Assistant

Type of MH Providers Psychiatrist Psychologist

Psychiatrist

PA

NP/Clinical Nurse Specialist

LCSW

PCP

Provides MH Services Yes Yes

 Evening Hours No No

 Weekends No No

 Plan for Emergencies 

Outside of Business Hours 

No No

 Provided Onsite Psychosocial Rehabilitation PTSD

MST

Psychosocial Rehabilitation

 Referrals Another VA facility Another VA facility

 Tele-Mental Health Services Yes (Medication Management) Yes (Medication Management)

Remote Services Tele-Audiology

Tele-Speech Pathology

Tele-Retinal

Specialty Care Services Onsite No No

 Referrals Another VA facility

Non-VA fee-basis or contract

Another VA facility

Ancillary Services Provided Onsite Laboratory (blood drawn

onsite)

Laboratory (blood drawn

onsite)

Onsite Pharmacy

EKG

Miles to Parent Facility 85 168

Affiliated Clinic Fountain Green Clinic None

Table 9. CBOC Characteristics 

VA OIG Office of Healthcare Inspections 12
 

 

Stamford, Waterbury, Goose Creek, Savannah, Nephi, and Pocatello

Quality of Care Measures 

DM

Diabetes is the leading cause of new cases of blindness among adults age 20−74, and 

diabetic retinopathy causes 12,000 to 24,000 new cases of blindness each year.

Detection and treatment of diabetic eye disease with laser therapy can reduce the

development of severe vision loss by an estimated 50−60 percent. Table 10 displays 

the parent facility and the Nephi and Pocatello CBOCs’ compliance in screening for

retinopathy.

Mea ure 

Meets 

Target Facility 

Qtr 3 

Numerator 

Qtr 3 

Denominator 

Qtr 3 

(%) 

DM – Retinal Eye 

Exam 

70% 660 VA Salt Lake City HCS 76 84 93 

660GI Nephi CBOC 31 37 84 

660GA Pocatello CBOC 46 50 92 

Table 10. Retinal Exam, FY 2010 

A1c is a blood test that measures average blood glucose (sugar) levels. Research

studies in the United States and abroad have found that improved glycemic control

benefits people with either type I or type II diabetes. In general, for every 1 percent

reduction in A1c, the relative risk of developing microvascular diabetic complications

(eye, kidney, and nerve disease) is reduced by 40 percent. The American Diabetes

Association recommends an A1c of less than 7 percent. Patients with poorly controlled

diabetes (A1c greater than 9 percent) are at higher risk of developing diabetic

complications. Measuring A1c assesses the effectiveness of therapy. For this

indicator, low scores indicate better compliance. Table 11 displays the scores of the

parent facility and the Nephi and Pocatello CBOCs.

Measure 

Meets 

Target Facility 

Qtr3 

Numerator 

Qtr 3 

Denominator 

Qtr 3 

(%) 

DM –A1c > 9 or not 

done in past year 

20% 660 VA Salt Lake City HCS 19 84 23 

660GI Nephi CBOC 5 37 14 

660GA Pocatello CBOC 4 50 8 

Table 11. A1c Testing, FY 2010 

Women’s Health

Breast cancer is the second most common type of cancer among American women,

with approximately 207,000 new cases reported each year. It is most common in

women over 50. Women whose breast cancer is detected early have more treatment

choices and better chances for survival. Screening by mammography (an x-ray of the

breast) has been shown to reduce mortality by 20–30 percent among women 40 and

older. Comparisons of the Nephi and Pocatello CBOCs to the parent facility’s breast

cancer screening are listed in Table 12.

VA OIG Office of Healthcare Inspections 13
&

Stamford, Waterbury, Goose Creek, Savannah, Nephi, and Pocatello

Measure 

Meets 

Target Facility 

Qtr 3 

Numerator 

Qtr 3 

Denominator 

Qtr 3 

(%) 

Mammography, 77% 660 VA Salt Lake City HCS 31 38 87 

50-69 years old 

660GI Nephi CBOC 4 7 57 

660GA Pocatello CBOC 14 21 67 

Table 12. Women’s Health, FY 2010 

To support quality improvement efforts, the Nephi CBOC has implemented a new

system to improve feedback of the performance measure findings to the contractor.

The mammography performance measure will be a focused area. Additionally, the

VA Salt Lake City HCS has drafted a new contract that specifically discusses contractor

responsibilities regarding performance measure standards. The Pocatello CBOC will

audit records to identify patients due for gender-specific screening, including

appropriate scheduling for screening of those patients.

C&P 

We reviewed the C P files of three providers at the Nephi CBOC and five providers and

the personnel folders of four nurses at the Pocatello CBOC. All providers possessed a

full, active, current, and unrestricted license; and privileges were appropriate for

services rendered. All nurses’ license and education requirements were verified and

documented. Service-specific criteria for OPPE had been developed and approved.

We found sufficient performance data to meet current requirements. OPPE included

competency criteria for privileges. However, we found the following area that needed

improvement.

Clinical Privileges

The PSB granted clinical privileges to providers for procedures that were not performed

at the Pocatello CBOC. For example, a provider was granted the privilege to perform

thoracentesis procedures, which is not a service provided at the CBOC. According to

VHA Handbook 1100.19, providers may only be granted privileges that are actually

performed at the VA-specific facility.

Recommendation 4: We recommended that the provider privileges are consistent with

the services provided at the Pocatello CBOC.

Management of Laboratory Results 

VHA Directive 2009-019 requires critical test results to be communicated to the ordering

provider or surrogate provider within a timeframe that allows for prompt attention and

appropriate clinical action to be taken. VHA also requires that the ordering provider

communicate test results to patients so that they may participate in health care

decisions. Each parent facility is required to develop a written policy for communicating

test results to providers and documenting communications in the medical record, to

include a system for surrogate providers to receive results when the ordering provider is

not available. In addition, ordering providers are required to communicate outpatient

VA OIG Office of Healthcare Inspections 14
Stamford, Waterbury, Goose Creek, Savannah, Nephi, and Pocatello

test results (those not requiring immediate attention) to patients no later than

14 calendar days from the date on which the results are available to the ordering

provider.

We reviewed the parent facility’s policies and procedures and the medical records of

patients who had tests resulting in critical values and normal values. We found the

following, with one process that needed improvement.

Critical Laboratory Results

We found that the Pocatello CBOC did not have effective processes in place to

communicate critical laboratory test results to patients. We reviewed the medical

records of 10 patients at the Pocotello CBOC who had critical laboratory results. We

found that 8 (80 percent) of the records contained documented evidence of patient

notification and follow-up actions. There were no patients at the Nephi CBOC who had

critical laboratory results for our review.

Recommendation 5: We recommended that ordering providers document patient

notification and treatment actions in response to critical laboratory test results at the

Pocatello CBOC.

Normal Laboratory Results

We found that both CBOCs had effective processes in place to communicate normal

laboratory test results to patients. We reviewed the medical records of 20 patients

(10 at the Nephi CBOC and 10 at the Pocatello CBOC) and determined that the CBOCs

had communicated normal results to all patients within 14 calendar days from the date

the results were available to the ordering provider.

Environment and Emergency Management 

EOC

To evaluate the EOC, we inspected patient care areas for cleanliness, safety, IC, and

general maintenance. Both CBOCs met most standards, and the environments were

generally clean and safe. We found that the IC program monitored data and

appropriately reported that data to relevant committees. Safety guidelines were

generally met, and risk assessments were in compliance with VHA standards.

Emergency Management

VHA Handbook 1006.1 requires each CBOC to have a local policy or SOP defining how

medical emergencies, including MH, are handled. Both CBOCs had policies that

outlined management of medical and MH emergencies, and staff at each facility

articulated responses that accurately reflected the local emergency response

guidelines.

VA OIG Office of Healthcare Inspections 15
Stamford, Waterbury, Goose Creek, Savannah, Nephi, and Pocatello

CBOC Contract 

Nephi CBOC

The contract for the Nephi CBOC is administered through the VA Salt Lake City HCS

for primary medical care for all eligible veterans in VISN 19. The Nephi CBOC occupies

space shared with private practice patients at the CVMC. The services were originally

purchased via a contract, V259P-4929, that was effective on December 1, 2004. The

contract, which was for a base year plus four 1-year options, was due to expire on

November 30, 2009. However, the contract was extended for 6 months through

March 31, 2010, pursuant to the provisions in the contract.

During our focused period, 3rd Qtr, FY 2010, CVMC was providing primary care services

on a sole source purchase order that was issued for April 1 through

September 30, 2010. At the time of our review, the CBOC was operating under a

second purchase order. Central Office approval was obtained for a 6-month period

from October 2010 until March 31, 2011. Additionally, the CVMC utilized a satellite

outpatient clinic in Fountain Green, UT for veterans in that area. There were 2.0 FTE

PCPs shared between the Nephi CBOC and Fountain Green clinic. The contractor was

compensated at an annual capitated rate per enrollee. The CBOC had 699 unique

primary medical care enrollees with 1,353 visits as reported on the FY 2010 CBOC

Characteristics report (see Table 9).

MH services are provided by VA staff utilizing tele-mental health equipment located at

the Nephi CBOC. During the period October 1, 2009, through June 30, 2010, VA MH

practitioners provided services to 23 veterans for 46 MH visits.

We reviewed the contract to determine the contract type, the services provided, the

invoices submitted, and supporting information. We also performed inquiries of key

VA Salt Lake City HCS and contractor personnel. Our review focused on documents

and records for 3rd Qtr, FY 2010. We reviewed the methodology for tracking and

reporting the number of enrollees in compliance with the terms of the contract. We

reviewed paid capitation rates for compliance with the contract; form and substance of

the contract invoices for ease of data analysis by the COTR; and duplicate, missing, or

incomplete SSNs on the invoices.

The PCMM Coordinator is responsible for maintaining currency of information in the

PCMM database. VA Salt Lake City HCS has approximately 35,000 active patients with

approximately 700 assigned to the Nephi CBOC. We reviewed PCMM data reported by

VHA Support Service Center and the VA Salt Lake City HCS for compliance with VHA

policies. We made inquiries about the number of patients who were unassigned,

assigned to more than one PCP, or potentially deceased.

We noted the following:

1.&Contracted services with CVMC were improperly continued under a sole source

emergency purchase order for April 1, 2010, through September 30, 2010. It

VA OIG Office of Healthcare Inspections& 16
Stamford, Waterbury, Goose Creek, Savannah, Nephi, and Pocatello

appears that the failure to compete and award a follow-on contract for the services

was due to poor acquisition planning. Under FAR Part 6,11 failure to plan is not an

acceptable basis for a sole-source contract. A long-term contract should have been

awarded competitively as required by law. The annual capitated rate under the

purchase order was increased 83 percent from the prior contract. There was no

documentation to support whether the 83 percent increase in cost was fair and

reasonable. Additionally, the purchase order improperly included a provision for a

6-month extension. Delays in the contracting process were attributed to a high

turnover of contracting officers involved in this case (three contracting officers within

the 6-month period ending September 30, 2010).

2.&Although the second purchase order stated that it had an effective period of

October 1, 2010, through March 31, 2011, the attached Statement of Work stated it

was for a 1-year base period with four 1-year option periods. This provision was not

only inconsistent with the term of the contract indicated on the purchase order, it

also exceeded the 180-day authority provided under the Interim Contract Authority12

signed on October 25, 2010, after the second purchase order was issued.

The “Schedule” section of the second purchase order identified the services to be

provided as “Primary Medical Care Services for vested patients seen in Nephi,” with

a specific quantity of patients at a unit price per patient. There is no explanation to

support the number of patients, or is there any documentation to support the price

as fair and reasonable. Notwithstanding that the quantity of patients should have

been an estimate, not a definitive quantity, because this was identified as a 6-month

contract, the quantity should have been half of the enrolled patients. Even

assuming that the intent was for the entire year, the number was inaccurate. As for

the price per unit, the price should have been lower per patient since this was a 6-

month contract and the price was an annual capitated rate.

3.&VA Salt Lake City HCS overpaid the contractor by approximately $119,000 by

making more than one annual capitated payment for the patients. We analyzed

billing data for April 1, 2009, through June 30, 2010. We found that additional

payments were made for each of the shortened periods during the purchase order

and extensions and not on an annual basis. Due to the time periods (6 months or

less) for the contract extension and emergency purchase order, the

VA Salt Lake City HCS compensated the contractor for some veterans three times in

a 12-month period.

4.&Contract provisions should include a prorated reduction of an annual capitated rate

payment for services provided less than 12 months. Without this provision, the VA

is paying for 12 months of care when the contract could be ending in a month.

11 Federal Acquisition Regulations, Part 6, March 2005.
 12 VA Directive 1663, Health Care Resources Contracting – Buying, Title 38 U.S.C. 8153, August 10, 2006.
 

VA OIG Office of Healthcare Inspections& 17
Stamford, Waterbury, Goose Creek, Savannah, Nephi, and Pocatello

5.&We noted that CVMC was paid approximately $38,000 (July 1, 2009, through

June 30, 2010) for vaccination fees for the veterans who received influenza or

pneumococcal vaccines at the CBOC. Vaccination services for eligible enrollees

were added in January 2007 to the contract as an incremental fee to the annual

capitated rate. The Medicare reimbursement rate for influenza and pneumococcal

vaccines are $13.21 and $37.61, respectively.

6.&VA Salt Lake City HCS continues to pay for space for tele-mental health services

from CVMC on a lease agreement that expired in April 2009.

7.&CVMC provides services to VA patients at a satellite clinic (Fountain Green), which

was not covered under the contract. This facility does not have direct access to the

VA’s electronic medical record system and is not reported as a primary care facility

in VA systems. VA Salt Lake City HCS was aware that patients were being seen at

this alternative location.

Recommendation 6. We recommended that the Contracting Officer make provisions

to ensure contracts are awarded within a timeframe in accordance with VA policies,

procedures, and directives to avoid the need for sole source emergency purchase

orders at the Nephi CBOC.

Recommendation 7. We recommended that the Facility Director assesses the

collectability of $119,000 in overpayments to the vendor with the assistance of the

Regional Counsel.

Recommendation 8. We recommended that the Facility Director initiates with the

Contracting Officer the necessary contract modifications for the satellite clinic.

Recommendation 9. We recommended that contract provision include a prorated

reduction of an annual capitated rate payment for services provided less than

12 months.

VA OIG Office of Healthcare Inspections& 18
Stamford, Waterbury, Goose Creek, Savannah, Nephi, and Pocatello

Appendix A 

VISN 1 Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: February 8, 2011

From: Director, VISN 1 (10N1)

Subject: CBOC Review: Stamford and Waterbury, CT 

To: Director, Bedford Regional Office of Healthcare Inspections

(54BN)

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

I concur with the findings submitted to the VA office of the Inspector

General (OIG) regarding the systematic review of the Veteran’s Health

Administration’s (VHA’s) community based outpatient care clinics located

in Stamford and Waterbury, Connecticut.

Michael Mayo-Smith, MD

Director, VISN 1

VA OIG Office of Healthcare Inspections 19
Stamford, Waterbury, Goose Creek, Savannah, Nephi, and Pocatello

Appendix B 

VA Connecticut HCS Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: 2/3/11

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

Subject: CBOC Review: Stamford and Waterbury, CT 

To: Director, VISN 1 (10N1)

This memorandum serves as our concurrence with the recommendations

found in this CBOC Review of VA Connecticut Healthcare System

Stamford and Waterbury sites which was conducted the week of

December 6, 2010. The implementation plan, showing specific corrective

actions and target completion dates, is attached.

Acting Director, VA Connecticut Healthcare System
 

VA OIG Office of Healthcare Inspections 20
Stamford, Waterbury, Goose Creek, Savannah, Nephi, and Pocatello

Comments to Office of Inspector General’s Report
	

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

to the Office of Inspector General’s report:

OIG Recommendations 

Recommendation 1. We recommended that facility managers fully implement a plan

for improvement in communication of normal test results to patients at the Stamford and

Waterbury CBOCs and monitor compliance.

Concur

Target date for completion: May 26, 2011 (3 data points to assure sustainment)

IMPLEMENTATION PLAN: VA Connecticut Healthcare System immediately discussed

this issue with the CBOC providers and staff and has educated them on documentation

requirements in the chart regarding the communication of normal lab results. The

CBOC providers will communicate to staff that a letter must be generated for the

notification of patient’s normal test results.

Monitoring of compliance with notification of normal test results at the CBOCs will be

conducted for no less than a period of three months and provider specific feedback will

be provided through Primary Care leadership.

Aggregate results of notification of normal test results 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.

Recommendation 2. We recommended that managers require monthly visual

inspections of all portable fire extinguishers at the Waterbury CBOC.

Concur

Target date for completion: April 28, 2011 (3 data points to assure sustainment)

IMPLEMENTATION PLAN: All fire extinguishers in the Waterbury CBOC will be

visually inspected monthly by the CBOC Nurse Manager. The documentation of this

inspection will be found on the tag located on each extinguisher. This process will take

place on all of the fire extinguishers in the building on a monthly basis during the Nurse

Manager’s onsite review. Should a fire extinguisher be found to be outdated the Nurse

Manager will alert the Waterbury Building Maintenance.

VA OIG Office of Healthcare Inspections 21
Stamford, Waterbury, Goose Creek, Savannah, Nephi, and Pocatello

Appendix C 

VISN 7 Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: February 14, 2011

From: Acting Director, VA Southeast Network, VISN 7 (10N7)

Subject: CBOC Reviews: Goose Creek, SC and Savannah, GA 

To: Director, Atlanta Office of Healthcare Inspections Division

(54AT)

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

I fully concur with the Medical Center Director’s response to

this report.

VA OIG Office of Healthcare Inspections 22
'

Stamford, Waterbury, Goose Creek, Savannah, Nephi, and Pocatello

Appendix D 

Ralph H. Johnson VAMC Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: February 10, 2011

From: Director, Ralph H. Johnson (534/00)

Subject: CBOC Reviews: Goose Creek, SC and Savannah, GA 

To: Acting Director, VA Southeast Network (10N7)

1. I have reviewed the draft report of the Inspector General s

Community Based Outpatient Clinic (CBOC) of the Goose

Creek, SC and Savannah, GA CBOCs. There was one

finding with a recommendation.

2. I concurred with the finding regarding exit signage, and

we have completed the action to resolve the issue.

3. I appreciate the opportunity for this review as a continuing

process to improve the care to our veterans.

(original signed by:)

CAROLYN L. ADAMS

VA OIG Office of Healthcare Inspections 23
Stamford, Waterbury, Goose Creek, Savannah, Nephi, and Pocatello

Comments to Office of Inspector General’s Report
	

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

to the Office of Inspector General’s report:

OIG Recommendations 

Recommendation 3. We recommended that exit signage be aligned to identify the

correct pathway of egress at the Goose Creek CBOC.

Concur

Target date for completion: Completed 2/2/11 

The building is actually the responsibility of the Naval Health Clinic (NHC). Our safety

staff collaborated with the staff at the NHC to have these corrections completed so that

the egress pathways are accurately identified.

VA OIG Office of Healthcare Inspections 24
Stamford, Waterbury, Goose Creek, Savannah, Nephi, and Pocatello

Appendix E 

VISN 19 Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: February 8, 2011

From: Director, Rocky Mountain Network (10N19)

Subject: CBOC Reviews: Nephi, UT and Pocatello, ID 

To: Director, Denver Office of Healthcare Inspections (54DV)

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

I have reviewed the response to the draft OIG CBOC report provided by

the George E. Wahlen VA Salt Lake City Health Care System and concur

with the response. I am submitting it to your office as requested. If you

have any questions or require additional information, please contact

Susan Curtis, VISN 19 Health System Specialist at (303) 639-6995.

VISN 19 Network Director
 

VA OIG Office of Healthcare Inspections 25
Stamford, Waterbury, Goose Creek, Savannah, Nephi, and Pocatello

Appendix F 

Salt Lake City HCS Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: January 31, 2011

From: Director, VA Salt Lake City HCS (660/00)

Subject: CBOC Reviews: Nephi, UT and Pocatello, ID 

To: Director, Rocky Mountain Network (10N19)

1.&I would like to express my sincere appreciation to the OIG CBOC

review team for their professionalism and consultative feedback to

our staff during the review, which was conducted December 6–9,

2010. We appreciate their thorough review and the opportunity to

further improve the quality care we provide Veterans every day.

2.&I have reviewed the recommendations and concur with the findings.

Our comments and planned actions are outlined below.

3.&If you have questions or require additional information, please do

not hesitate to contact Nena Saunders, Chief, Quality Management,

at (801) 582-1565, ext. 4608.

Director, George E. Wahlen VA Salt Lake City Health Care System
 

VA OIG Office of Healthcare Inspections& 26
Stamford, Waterbury, Goose Creek, Savannah, Nephi, and Pocatello

Comments to Office of Inspector General’s Report
	

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

to the Office of Inspector General’s report:

OIG Recommendations 

Recommendation 4. We recommended that the provider privileges are consistent with

the services provided at the Pocatello CBOC.

Concur

Target date for completion: March 1, 2011

Facility’s response. While the OIG was on-site, the Professional Standards Board met

and revised the privileges for the provider who was identified by the OIG. His privilieges

are now consistent with services provided at that CBOC. Credentialing and Privileging

staff also conducted a 100 percent review of other providers’ privileges in the CBOCs

and found no other discrepancies.

Recommendation 5. We recommended that ordering providers document patient

notification and treatment actions in response to critical laboratory test results at the

Pocatello CBOC.

Concur

Target date for completion: Ongoing monitoring completion target date May 1, 2011

Facility’s response. Policy existed which require that critical test results be consistently

communicated to patients within 14 days; however, this was not being adhered to by

medical providers. The Chief of Staff conducted staff education and reinforced the

policy in the Clinical Executive Committee. The Chief of Staff also plans to reinforce

education in all Provider-Service Chief meetings and through electronic messages. The

Medical Records Committee will conduct an audit of 100 medical records of veterans

served in the CBOCs per month during the months of February, March, and April 2011

to validate 90 percent compliance with VHA Directive and local policy.

Recommendation 6. We recommended that the Contracting Officer make provisions

to ensure contracts are awarded within a timeframe in accordance with VA policies,

procedures, and directives to avoid the need for sole source emergency purchase

orders at the Nephi CBOC.

Concur

Target date for completion: April 1, 2011

VA OIG Office of Healthcare Inspections 27
Stamford, Waterbury, Goose Creek, Savannah, Nephi, and Pocatello

Facility’s response. The VISN19 Contracting Office developed a procurement checklist

which is being sent to all COTR by the Contracting Officer at least 90–120 days prior to

the end of an option year and or expiration of a contract. This checklist identifies the

documents that are required by the COTR to ensure the Contracting Officer has

sufficient time to process these documents to exercise an option or award a new

contract.

A new interim contract has been approved by the medical sharing office for a 6-month

period (April 1, 2011 through September 30, 2011) with an option for an additional

6 months until the new long-term Nephi contract is awarded.

The Contracting Officer has completed the long-term Nephi solicitation and it is going

through internal contract review. The anticipated issuance date of the solicitation is

February 15, 2011. This solicitation will be advertised “competitively” with a base year

and four 1-year options. The award of this solicitation will ensure we have a long-term

plan to ensure Veterans receive treatment without interruption of services.

Recommendation 7. We recommended that the Facility Director assesses the

collectability of $119,000 in overpayments to the vendor with the assistance of the

Regional Counsel.

Concur

Target date for completion: April 1, 2011

Facility’s response. We have had discussions with Regional Counsel concerning the

potential overpayment and the Government’s course of action.

We are gathering further documentation to review with Regional Counsel to explore

potential legal avenues to recoup potential overpayment.

Recommendation 8. We recommended that the Facility Director initiates with the

Contracting Officer the necessary contract modifications for the satellite clinic.

Concur

Target date for completion: May 1, 2011

Facility’s response. The VISN 19 Contracting Office will work closely with the Facility

Director to ensure the necessary contract modifications are executed for the satellite

clinic, as appropriate.

Contract modifications are dependent on the final course of action in

recommendation 4.

Recommendation 9. We recommended that contract provision include a prorated

reduction of an annual capitated rate payment for services provided less than

12 months.

VA OIG Office of Healthcare Inspections 28
Stamford, Waterbury, Goose Creek, Savannah, Nephi, and Pocatello

Concur

Target date for completion: Completed January 31, 2011, and will be included in all

future contracts

Facility’s response. For the short and long-term Primary Care Services in the Nephi

contract, the Contracting Office will ensure that the following contract provision is

incorporated into the contract:

“Veterans who complete the enrollment process for care through the VA and who

choose to receive primary care at the CBOC will be covered under this contract. Active

numbers for reimbursement are tracked through the PCMM system maintained by the

clinic/VA clerks. The PCMM is reviewed monthly to adjust for patient deaths, new

patients not assigned, and removal of patients not seen in a 12-month period. All new

Active members receiving services under this agreement shall be added to the PCMM

panel after the initial visit." The Capitated Rate payment shall be based on per member

per month.

VA OIG Office of Healthcare Inspections 29
Stamford, Waterbury, Goose Creek, Savannah, Nephi, and Pocatello

Appendix G 

OIG Contact and Staff Acknowledgments 

Contact for		 Claire McDonald, MPA

Stamford and Director, Bedford Regional Office of Healthcare Inspections

Waterbury 

(VISN 1) 

Contact for		 Nancy Albaladejo, RN

Goose Creek Atlanta Office of Healthcare Inspections

and Savannah 

(VISN 7) 

Contact for		 Virginia L. Solana, RN

Nephi and Denver Office of Healthcare Inspections

Pocatello 

(VISN 19) 

Contributors		 Annette Acosta, RN

Shirley Carlile, BA

Lin Clegg, Ph.D.

Marnette Dhooghe, MS

Laura L. Dulcie, BS

Stephanie B. Hensel, RN, JD

Elaine Kahigian, RN, JD

Jeanne Martin, PharmD

Roxanna Osegueda

Clarissa B. Reynolds, MBA

Thomas J. Seluzicki, CPA

Barry L. Simon, VMD

Lynn Sweeney, MD

Ann Ver Linden, RN

Cheryl A. Walker, NP

Susan Zarter, RN

VA OIG Office of Healthcare Inspections& 30
Stamford, Waterbury, Goose Creek, Savannah, Nephi, and Pocatello

Appendix H 

Report Distribution 

VA Distribution 

Office of the Secretary

Veterans Health Administration

Assistant Secretaries

General Counsel

Director, VISN 1 (10N1)

Acting Director, VA Connecticut HCS (689/00)

Acting Director, VISN 7 (10N7)

Director, Ralph H. Johnson VAMC (534/00)

Director, VISN 19 (10N19)

Director, VA Salt Lake City HCS (660/00)

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, Saxby Chambliss, Mike Crapo, Jim DeMint, Lindsey

Graham, Orrin G. Hatch, Johnny Isakson, Mike Lee, Joseph I. Lieberman, James E.

Risch

U.S. House of Representatives: John Barrow, Rob Bishop, Jason Chaffetz, James A.

Himes, Jim Matheson, Christopher S. Murphy, Tim Scott, Michael K. Simpson

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

VA OIG Office of Healthcare Inspections 31