Department of Veterans Affairs 

Office of Inspector General 

Office of Healthcare Inspections 

Report No. 11-00840-104 

Community Based Outpatient
 

Clinic Reviews
 

Spring City and Springfield, PA
 

Sarasota and Sebring, FL
 

Paragould, AR and Salem, MO
 

Cottonwood and Lake Havasu City, AZ
 

February 28, 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) 
Spring City, Springfield, Sarasota, Sebring, Paragould, Salem, Cottonwood, and Lake Havasu City 

Glossary 

A1c glycated hemoglobin 

ADA Americans with Disabilities Act 

C&P credentialing and privileging 

CBOC community based outpatient clinic 

CDC Centers for Disease Control and Prevention 

DM Diabetes Mellitus 

EKG electrocardiogram 

EOC environment of care 

FY fiscal year 

FTE full-time employee equivalents 

HCS Health Care System 

IC infection control 

IT Information Technology 

LCSW Licensed Clinical Social Worker 

LPN Licensed Practical Nurse 

MH mental health 

MST military sexual trauma 

NAVAHCS Northern Arizona VA Health Care System 

NFPA National Fire Protection Association 

NP nurse practitioner 

OIG Office of Inspector General 

OI&T Office of Information and Technology 

OPPE Ongoing Professional Practice Evaluation 

OSHA Occupational Safety and Health Administration 

PA physician assistant 

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 
Spring City, Springfield, Sarasota, Sebring, Paragould, Salem, Cottonwood, and Lake Havasu City 

Table of Contents 

Page
 

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

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

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

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

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

VISN 4, Coatesville VAMC –Spring City and Springfield ........................................ 3
 

VISN 8, Bay Pines HCS –Sarasota and Sebring .................................................... 8
 

VISN 15, John J. Pershing VAMC – Paragould and Salem .................................... 13
 

VISN 18, NAVAHCS – Cottonwood and Lake Havasu City .................................... 18
 

Appendixes 

A. VISN 4 Director Comments ............................................................................... 23
 

B. Coatesville VAMC Director Comments.............................................................. 24
 

C. VISN 8 Director Comments ............................................................................... 26
 

D. Bay Pines HCS Director Comments.................................................................. 27
 

E. VISN 15 Director Comments ............................................................................. 30
 

F. John J. Pershing VAMC Director Comments..................................................... 31
 

G. VISN 18 Director Comments.............................................................................. 34
 

H. NAVAHCS Interim Director Comments.............................................................. 35
 

I. OIG Contact and Staff Acknowledgments ......................................................... 39
 

J. Report Distribution............................................................................................. 40
 

VA OIG Office of Healthcare Inspections 
Spring City, Springfield, Sarasota, Sebring, Paragould, Salem, Cottonwood, and Lake Havasu City 

Executive Summary 

Purpose: We conducted the review of eight CBOCs during the weeks of November 

15, 2010, and November 29, 2010. CBOCs were reviewed in VISN 4 at Spring City and 

Springfield, PA; in VISN 8 at Sarasota and Sebring, FL; in VISN 15 at Paragould, AR 

and Salem, MO; and, in VISN 18 at Cottonwood and Lake Havasu City, AZ. The parent 

facilities of these CBOCs are Coatesville VAMC, Bay Pines HCS, John J. Pershing 

VAMC, and Northern Arizona VA Health Care System (NAVAHCS), respectively. The 

purpose was to evaluate selected activities, assessing whether the CBOCs are 

operated in a manner that provides veterans with consistent, safe, high-quality health 

care. 

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

respective CBOC manager, should take appropriate actions to: 

Coatesville VAMC 

	 Modify the entrance to improve access for disabled veterans at the Springfield 

CBOC. 

	 Develop a procedure for monitoring and testing panic alarms at the Spring City 

CBOC. 

	 Collect and monitor measurable data for hand hygiene at the Spring City and 

Springfield CBOCs. 

Bay Pines HCS 

	 Collect, analyze, and report hand hygiene data at the Sarasota and Sebring CBOCs. 

	 Identify the locations of fire extinguishers at the Sarasota and Sebring CBOCs. 

	 Improve access for disabled veterans at the Sebring CBOC. 

	 Update the local policy for medical and MH emergencies at the Sarasota CBOC. 

John J. Pershing VAMC 

	 Require providers to document patient notification of normal labs within the specified 

timeframe at the Paragould CBOC. 

	 Collect, analyze, and report hand hygiene data at the Paragould and Salem CBOCs. 

	 Conduct fire drills at the Salem CBOC as required by the NFPA. 

	 Require that the parent facility follows VA directives and guidelines for real property 

lease agreements for the Salem CBOC. 

VA OIG Office of Healthcare Inspections i 
Spring City, Springfield, Sarasota, Sebring, Paragould, Salem, Cottonwood, and Lake Havasu City 

	 Require that the parent facility enter into a contract to perform laboratory and other 

medical services at negotiated prices for the Salem CBOC, or if a contract is not 

beneficial to the VA, then the Facility Director must ensure that VA directives and 

guidelines for fee basis care are followed. 

NAVAHCS 

	 Require the ordering providers at the Cottonwood CBOC to document patient 

notification and treatment actions in response to critical test results. 

	 Ensure clinicians communicate normal test results to patients within the specified 

timeframe at the Lake Havasu City CBOC. 

	 Require the Chief of OI&T to evaluate identified IT security vulnerabilities and 

implement appropriate IT security measures at the Cottonwood and Lake Havasu 

City CBOCs. 

	 Install panic alarm systems at the Cottonwood and Lake Havasu City CBOCs. 

	 Maintain auditory privacy during the check-in process at the Cottonwood CBOC. 

	 Develop a local policy or SOP for handling medical and MH emergencies at the 

Cottonwood and Lake Havasu City CBOCs. 

Comments 

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

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

pages 23-38 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 
Spring City, Springfield, Sarasota, Sebring, Paragould, Salem, Cottonwood, and Lake Havasu City 

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. 

Scope. The topics discussed in this report include: 

 Quality of Care Measures 

 C&P 

 Management of Laboratory Results 

 EOC and Emergency Management 

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 

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 2009-019.3 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 

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

VA OIG Office of Healthcare Inspections 1 
Spring City, Springfield, Sarasota, Sebring, Paragould, Salem, Cottonwood, and Lake Havasu City 

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 conducted the inspection in accordance with Quality Standards for Inspection and 

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

Efficiency. 

VA OIG Office of Healthcare Inspections 2 
Spring City, Springfield, Sarasota, Sebring, Paragould, Salem, Cottonwood, and Lake Havasu City 

Part II. Results and Recommendations 

A. VISN 4, Coatesville VAMC – Spring City and Springfield 

CBOC Characteristics 

Table 1 shows the characteristics of the Spring City and Springfield CBOCs. 

CBOC Characteristics Spring City Springfield 

Type of CBOC VA Staffed VA Staffed 

Number of Uniques, FY 2010 2,920 3,718 

Number of Visits, FY 2010 8,697 11,244 

CBOC Size4 Mid-Size Mid-Size 

Locality Urban Urban 

FTE 2.5 3.8 

Type Providers Assigned PCP 

PA 

Psychiatrist 

Psychologist 

LCSW 

PCP 

PA 

Psychiatrist 

Psychologist 

LCSW 

Ancillary Staff Assigned RN 

LPN 

Pharmacist 

Social Worker 

Technician/Technologist 

RN 

LPN 

Pharmacist 

Social Worker 

Technician/Technologist 

Type of MH Providers Psychologist 

Psychiatrist 

PA 

LCSW 

Psychologist 

Psychiatrist 

LCSW 

Provides MH Services Yes Yes 

 Evening Hours Yes Yes 

 Weekends No No 

 Plan for Emergencies 

Outside of Business Hours 

No No 

 Provided Onsite Substance Use Disorder 

PTSD 

MST 

Homelessness 

Psychosocial Rehabilitation 

Substance Use Disorder 

PTSD 

MST 

Homelessness 

Psychosocial Rehabilitation 

 Referrals Another VA facility Another VA facility 

 Tele-Mental Health Services No No 

Remote Services Tele-Retinal Services Tele-Retinal Services 

Specialty Care Services Onsite No Yes 

 Type N/A Women’s Health 

 Referrals Another VA facility 

Non-VA fee-basis or contract 

Another VA facility 

Non-VA fee-basis or contract 

Ancillary Services Provided Onsite Laboratory (Blood drawn) 

EKG 

Laboratory (Blood drawn) 

EKG 

Miles to Parent Facility 25 25 

Table 1: CBOC Characteristics 

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

VA OIG Office of Healthcare Inspections 3 
 

 

Spring City, Springfield, Sarasota, Sebring, Paragould, Salem, Cottonwood, and Lake Havasu City 

Quality of Care Measures5 

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 Spring City and Springfield CBOCs’ compliance in screening for 

retinopathy. 

Measure 

Meets 

Ta ge 

t Facility 

Qtr 3 

Numerato 

Qtr 3 

Denominator 

Qtr 3 

(%) 

DM – Retinal Eye 

Exam 

70% 542 Coatesville VAMC 22 24 94 

542GE Spring City CBOC 47 50 94 

542GA Springfield CBOC 50 50 100 

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 Spring City and Springfield CBOCs. 

Measure 

Meets 

Target Facility 

Qtr 3 

Numerator 

Qtr 3 

Denominator 

Qtr 3 

(%) 

DM –A1c > 9 or not 

done in past year 

21% 542 Coatesville VAMC 3 24 14 

542GE Spring City CBOC 4 50 8 

542GA Springfield CBOC 5 50 10 

Table 3. A1c Testing, FY 2010 

5 The parent facility’s 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 
Spring City, Springfield, Sarasota, Sebring, Paragould, Salem, Cottonwood, and Lake Havasu City 

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.6 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 parent facility’s breast cancer screening results are listed in Table 4. 

Neither CBOC had patients who met the criteria for our review; therefore, we were not 

able to compare the CBOCs to the parent facility. 

Measure 

Meets 

Target Facility 

Qtr 3 

Numerator 

Qtr 3 

Denominator 

Qtr 3 

(%) 

Mammography, 

50-69 years old 

77% 542 Coatesville VAMC 21 26 86 

542GE Spring City CBOC NA NA NA 

542GA Springfield CBOC NA NA NA 

Table 4. Women’s Health, FY 2010 

C&P 

We reviewed the C&P files of two providers and the personnel folders of two nurses at 

the Spring City CBOC and three providers and two nurses at the Springfield 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 minimum 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. 

6 American Cancer Society, Cancer Facts & Figures 2009. 

VA OIG Office of Healthcare Inspections 5 
Spring City, Springfield, Sarasota, Sebring, Paragould, Salem, Cottonwood, and Lake Havasu City 

We determined that the parent facility had developed a written policy and had 

implemented an effective reporting process for test results. 

Critical Laboratory Results 

We found that the Spring City and Springfield 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 Spring City CBOC and 10 at the 

Springfield 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 Spring City and Springfield 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 Spring City CBOC and 10 at the Springfield CBOC) 

and determined that the CBOCs had communicated normal results to 19 (95 percent) 

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. However, we identified the following areas that needed 

improvement. 

Physical Access 

The Springfield CBOC entrance door handle required a tight grasp to open, and the 

door was not equipped with an automatic opener or bell to assist patients in accessing 

the clinic. The ADA7 requires that facility doors be equipped with handles that are 

easy to grasp with one hand and do not require tight grasping, pinching, or twisting of 

the wrist to operate. 

Panic Alarms 

The Spring City CBOC staff did not monitor or test the panic alarms. The Spring City 

CBOC staff carry a hand-held alarm on a voluntary basis. When an alarm is activated, 

all staff are to respond to assist the staff member activating the alarm. During our site 

7 ADA, ADA Standards for Accessible Design, accessed on November 18, 2010. 

VA OIG Office of Healthcare Inspections 6 
Spring City, Springfield, Sarasota, Sebring, Paragould, Salem, Cottonwood, and Lake Havasu City 

visit, we tested the process; however, all staff did not respond. Staff who did not 

respond reported that the alarm was audible. OSHA8 requires that panic alarm 

systems be monitored and tested to minimize risk to employees and visitors. 

Hand Hygiene Monitor 

We found no documentation that hand hygiene data had been collected. Therefore, 

the facility could not identify any trends or conduct the appropriate data analysis. 

Although, the CBOC manager and the IC Officer recently initiated a process of data 

collection, no data was available for our review at the time of our site visit. The CDC9 

recommends that healthcare facilities develop a comprehensive IC program with a 

hand hygiene component that includes monitors, data analysis, and provider feedback. 

The intent is to foster a culture of hand hygiene compliance that ensures the control of 

infectious diseases. 

Recommendation 1: We recommended that the entrance be modified to improve 

access for disabled veterans at the Springfield CBOC. 

Recommendation 2: We recommended that a procedure for monitoring and testing 

panic alarms be developed for the Spring City CBOC. 

Recommendation 3: We recommended that data for hand hygiene is collected and 

monitored for the Spring City and Springfield CBOCs. 

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. Our interviews revealed staff 

at each facility articulated responses that accurately reflected the local emergency 

response guidelines. 

8 Guidelines for Preventing Workplace Violence for Health Care & Social Service Workers – OSHA Publication
 

3148 (2004).

9 CDC is one of the components of the Department of Health and Human Services that is responsible for health
 

promotion; prevention of disease, injury, and disability; and preparedness for new health threats.
 

VA OIG Office of Healthcare Inspections 7 
Spring City, Springfield, Sarasota, Sebring, Paragould, Salem, Cottonwood, and Lake Havasu City 

B. VISN 8, Bay Pines HCS – Sarasota and Sebring 

CBOC Characteristics 

Table 5 shows the characteristics of the Sarasota and Sebring CBOCs. 

CBOC Characteristics Sarasota Sebring 

Type of CBOC VA Staffed VA Staffed 

Number of Uniques, FY 2010 13,418 3,064 

Number of Visits, FY 2010 77,111 23,569 

CBOC Size Very Large Mid-Size 

Locality Urban Rural 

FTE 8.95 1.96 

Type Providers Assigned Internal Medicine Physician 

PCP 

Psychiatrist 

Psychologist 

LCSW 

Internal Medicine Physician 

PCP 

NP 

Psychiatrist 

LCSW 

Ancillary Staff Assigned RN 

LPN 

Pharmacist 

Social Worker 

Health/Medical 

Technician or Assistant 

Audiology Technician 

RN 

LPN 

Pharmacist 

Social Worker 

Health/Medical 

Technician or Assistant 

Type of MH Providers Psychologist 

Psychiatrist 

LCSW 

PCP 

Psychiatrist 

LCSW 

PCP 

NP 

Provides MH Services Yes Yes 

 Evening Hours No No 

 Weekends No No 

 Plan for Emergencies 

Outside of Business Hours 

No No 

 Provided Onsite Substance Use Disorder 

PTSD 

Substance Use Disorder 

PTSD 

 Referrals Another VA facility Another VA facility 

 Tele-Mental Health Services No Yes (Medication 

management and 

individual therapy) 

Remote Services Tele-Medicine 

Tele-Retinal 

Tele-Medicine 

Specialty Care Services Onsite Yes No 

 Type Women’s Health 

Audiology 

N/A 

 Referrals Another VA facility Another VA facility 

Ancillary Services Provided Onsite Laboratory (Blood drawn) 

EKG 

Laboratory (Blood drawn) 

EKG 

Miles to Parent Facility 51 105 

Table 5: CBOC Characteristics 

VA OIG Office of Healthcare Inspections 8 
 

 

Spring City, Springfield, Sarasota, Sebring, Paragould, Salem, Cottonwood, and Lake Havasu City 

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. While onsite, we 

learned that many veterans cancel or fail to keep their eye appointments at the parent 

facility because of the distance between the Sebring CBOC and the parent facility. The 

Sebring CBOC now has a retinal imaging camera, and eye exams should increase. 

Table 6 displays the parent facility and the Sarasota and Sebring CBOCs’ compliance in 

screening for retinopathy. 

Measure 

Meets 

Target Facility 

Qtr 3 

Numerator 

Qtr 3 

Denominator 

Qtr 3 

(%) 

DM – Retinal Eye 

Exam 

70% 516 Bay Pines VA HCS 82 90 91 

516GA Sarasota CBOC 43 47 91 

516GH Sebring CBOC 38 47 81 

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 Sarasota and Sebring CBOCs. 

Measure 

Meets 

Target Facility 

Qtr3 

Numerator 

Qtr 3 

Denominator 

Qtr 3 

(%) 

DM –A1c > 9 or not 

done in past year 

22% 516 Bay Pines VA HCS 17 90 16 

516GA Sarasota CBOC 5 47 11 

516GH Sebring CBOC 3 47 6 

Table 7. 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 

VA OIG Office of Healthcare Inspections 9 
Spring City, Springfield, Sarasota, Sebring, Paragould, Salem, Cottonwood, and Lake Havasu City 

older. Comparison of the Sarasota and Sebring CBOCs to the parent facility’s breast 

cancer screening is listed in Table 8. 

Measure 

Meets 

Target Facility 

Qtr 3 

Numerator 

Qtr 3 

Denominator 

Qtr 3 

(%) 

Mammography, 

50-69 years old 

77% 516 Bay Pines VA HCS 34 37 91 

516GA Sarasota CBOC 20 20 100 

516GH Sebring CBOC 26 26 100 

Table 8. Women’s Health, FY 2010 

C&P 

We reviewed the C&P files of three providers and the personnel folders of two nurses at 

the Sarasota CBOC and two providers and two nurses at the Sebring 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 minimum 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 policies and procedures and the medical records of patients who had tests 

resulting in critical and normal values. The parent facility had developed a written policy 

that included CBOCs, and we determined that both CBOCs had implemented an 

effective reporting process for test results. 

Critical Laboratory Results 

We found that the Sarasota and Sebring 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 Sarasota CBOC and 10 at the 

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

documented evidence of patient notification and follow-up actions. 

VA OIG Office of Healthcare Inspections 10 
Spring City, Springfield, Sarasota, Sebring, Paragould, Salem, Cottonwood, and Lake Havasu City 

Normal Laboratory Results 

We found that the Sarasota and Sebring 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 Sarasota CBOC and 10 at the Sebring CBOC) and 

determined that the CBOCs had communicated normal results to 18 (90 percent) 

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. Safety guidelines were generally met, and risk assessments 

were in compliance with VHA standards. However, we found the following areas that 

needed improvement. 

Hand Hygiene Monitor 

Staff at the Sarasota and Sebring CBOCs did not consistently collect hand hygiene data 

nor was the data analyzed. The CDC recommends that healthcare facilities develop a 

comprehensive hand hygiene program, which includes monitors, data analysis, and 

provider feedback. The intent is to foster a culture of hand hygiene compliance that 

promotes IC. 

Life Safety 

The Sarasota and Sebring CBOCs did not have signage to identify fire extinguishers 

located in recessed walls or stored in cabinetry. The NFPA Life Safety Code requires 

identification of fire extinguisher locations when they are obscured from view. 

Physical Access 

We observed a patient, using a walking cane, encounter difficulty opening the door to 

the Sebring CBOC. There was no doorbell or automatic door opener for patients to 

attain access to the clinic. In addition, the entrance door was not visible by staff; 

therefore, staff would not be aware if a patient needed assistance. 

Recommendation 4: We recommended that hand hygiene data be collected, 

analyzed, and reported at the Sarasota and Sebring CBOCs. 

Recommendation 5: We recommended installation of signage to identify the location 

of fire extinguishers at the Sarasota and Sebring CBOCs. 

VA OIG Office of Healthcare Inspections 11 
Spring City, Springfield, Sarasota, Sebring, Paragould, Salem, Cottonwood, and Lake Havasu City 

Recommendation 6: We recommended that access for disabled veterans be 

improved at the Sebring CBOC. 

Emergency Management 

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

medical emergencies, including MH, are handled. The Sebring CBOC had policies that 

outlined management of medical and MH emergencies, and our interviews revealed 

staff at the CBOC articulated responses that accurately reflected the local emergency 

management guidelines. However, the Sarasota CBOC policy did not include current 

procedures for management of medical and MH emergencies. For example, the policy 

did not reference the use of an automated electronic defibrillator for cardiac 

emergencies or the panic alarm system for MH emergencies. 

Recommendation 7: We recommended revising the local policy for medical and MH 

emergencies to reflect the current practice and capability at the Sarasota CBOC. 

VA OIG Office of Healthcare Inspections 12 
Spring City, Springfield, Sarasota, Sebring, Paragould, Salem, Cottonwood, and Lake Havasu City 

C. VISN 15, John J. Pershing VAMC – Paragould and Salem 

CBOC Characteristics 

Table 9 shows the characteristics of the Paragould and Salem CBOCs. 

CBOC Characteristics Paragould Salem 

Type of CBOC VA Staffed VA Staffed 

Number of Uniques, FY 2010 2,074 155 

Number of Visits, FY 2010 13,311 297 

CBOC Size Mid-Size Small 

Locality Rural Rural 

FTE 2 0.1 

Type Providers Assigned PCP 

NP 

NP 

Ancillary Staff Assigned RN 

LPN 

LPN 

Type of MH Providers Psychologist 

Rehabilitation 

Adjustment Counselor 

N/A 

Provides MH Services Yes No 

 Evening Hours Yes N/A 

 Weekends No N/A 

 Plan for Emergencies 

Outside of Business Hours 

No No 

 Provided Onsite Substance Use Disorder 

PTSD 

MST 

Homelessness 

N/A 

 Referrals Another VA facility 

Non-VA fee-basis or 

contract 

Another VA facility 

Non-VA fee-basis or 

contract 

 Tele-Mental Health Services Yes (Medication 

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 Laboratory (Blood drawn) 

Radiology 

None 

Miles to Parent Facility 60 118 

Table 9: CBOC Characteristics 

VA OIG Office of Healthcare Inspections 13 
 

 

Spring City, Springfield, Sarasota, Sebring, Paragould, Salem, Cottonwood, and Lake Havasu City 

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 Paragould and Salem CBOCs’ compliance in screening for 

retinopathy. 

Measure 

Meets 

Target Facility 

Qtr 3 

Numerator 

Qtr 3 

Denominator 

Qtr 3 

(%) 

DM – Retinal Eye 

Exam 

70% 657 John J. Pershing VAMC 44 52 90 

657GG Paragould CBOC 42 45 93 

657GN Salem CBOC 1 2 50 

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 Paragould and Salem CBOCs. 

Measure 

Meets 

Target Facility 

Qtr3 

Numerator 

Qtr 3 

Denominator 

Qtr 3 

(%) 

DM –A1c > 9 or not 

done in past year 

19% 657 John J. Pershing 

VAMC 

8 52 16 

657GG Paragould CBOC 7 46 15 

657GN Salem CBOC 0 2 0 

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. Comparison of the Paragould CBOC’s compliance to the parent facility’s breast 

VA OIG Office of Healthcare Inspections 14 
Spring City, Springfield, Sarasota, Sebring, Paragould, Salem, Cottonwood, and Lake Havasu City 

cancer screening compliance is listed in Table 12. The Salem CBOC had no patients 

who met the criteria for our review. 

Measure 

Meets 

Target Facility 

Qtr 3 

Numerator 

Qtr 3 

Denominator 

Qtr 3 

(%) 

Mammography, 

50-69 years old 

77% 657 John J. Pershing 

VAMC 

19 24 81 

657GG Paragould CBOC 12 14 86 

657GN Salem CBOC NA NA NA 

Table 12. Women’s Health, FY 2010 

C&P 

We reviewed the C&P files of one physician, three NPs, and the personnel folders of 

two nurses at the Paragould CBOC and one NP and one nurse at the Salem CBOC. All 

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

scope of practices 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 minimum 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, 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 Paragould and Salem CBOCs had effective processes in place to 

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

VA OIG Office of Healthcare Inspections 15 
Spring City, Springfield, Sarasota, Sebring, Paragould, Salem, Cottonwood, and Lake Havasu City 

reviewed the medical records of 11 patients (10 at the Paragould CBOC and 1 at the 

Salem CBOC10) 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 the Paragould CBOC did not have consistent processes in place to 

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

records of 20 patients (10 at the Salem CBOC and 10 at the Paragould CBOC) and 

determined that the Paragould CBOC had not communicated normal test results to 

5 (50 percent) of the patients within 14 calendar days from the date the results were 

available to the ordering provider. 

Recommendation 8: We recommended that normal test results be communicated to 

patients within the specified timeframe at the Paragould CBOC. 

Environment and Emergency Management 

EOC 

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

general maintenance. Both Paragould and Salem CBOCs met most standards, and the 

environments were generally clean and safe. Safety guidelines were generally met, 

and risk assessments complied with VHA standards. However, we found the following 

areas that needed improvement. 

Hand Hygiene Monitor 

The parent facility did not begin monitoring and collecting hand hygiene data at the 

Paragould and Salem CBOCs until August 2010. The CDC recommends that 

healthcare facilities develop a comprehensive IC program with a hand hygiene 

component which includes monitors, data analysis, and provider feedback. The intent 

is to foster a culture of hand hygiene compliance that ensures the control of infectious 

diseases. 

Fire Drills 

Fire drills were not conducted annually at the Salem CBOC. We found documentation 

of one fire drill conducted in 2010 but none for the previous year. According to the 

NFPA, staff must conduct, critique, and document fire drills every 12 months from the 

date of the last drill. 

Recommendation 9: We recommended that hand hygiene data is collected, analyzed, 

and reported for the Paragould and Salem CBOCs. 

10 Only one patient was identified with a critical lab. This may have been attributed to the small number of patients 

cared for at the Salem CBOC (155 uniques). 

VA OIG Office of Healthcare Inspections 16 
Spring City, Springfield, Sarasota, Sebring, Paragould, Salem, Cottonwood, and Lake Havasu City 

Recommendation 10: We recommended that fire drills be conducted at the Salem 

CBOC as required by NFPA. 

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 Paragould and Salem CBOCs 

had policies that outlined management of medical and MH emergencies. Our 

interviews revealed staff at each facility articulated responses that accurately reflected 

the local emergency response guidelines. 

CBOC Leasing Contract 

The Salem CBOC was located at the Salem Memorial District Hospital in leased space 

for clinic operations 3 days per month. The lease agreement signed on 

December 14, 1999, was for a 3-year period. The contract did not include a provision 

to authorize extension past the original 3-year period. The lease was amended three 

separate times by adding 3-year extensions, which extended the original lease to 

12 years ending on December 31, 2011. These amendments were signed on 

December 27, 2002, September 30, 2005, and November 19, 2008, respectively. 

We found that VA providers at the Salem CBOC were referring patients directly to the 

Salem Memorial District Hospital for laboratory and other medical services without a fee 

basis preauthorization form. The fee basis program requires preauthorization with an 

exception for emergencies. The fee basis documentation allows the patient a choice on 

where those services could be performed. Although the laboratory and radiology 

services were offered in Salem Memorial District Hospital’s proposal for the leasing 

arrangement, VA never entered into a contract with Salem Memorial District Hospital to 

purchase the services. 

Recommendation 11: We recommended that VA directives and guidelines for real 

property lease agreements are followed. 

Recommendation 12: We recommended that VA enter into a contract to perform 

laboratory and other medical services for VA at negotiated prices, or if a contract is not 

beneficial to the VA, then the Facility Director must ensure that VA directives and 

guidelines for fee basis care are followed. 

VA OIG Office of Healthcare Inspections 17 
Spring City, Springfield, Sarasota, Sebring, Paragould, Salem, Cottonwood, and Lake Havasu City 

D. VISN 18, NAVAHCS – Cottonwood and Lake Havasu City 

CBOC Characteristics 

Table 13 shows the characteristics of the Cottonwood and Lake Havasu City CBOCs. 

CBOC Characteristics Cottonwood Lake Havasu City 

Type of CBOC VA Staffed VA Staffed 

Number of Uniques, FY 2010 2,144 2,932 

Number of Visits, FY 2010 7,192 9,804 

CBOC Size Mid-Size Mid-Size 

Locality Rural Rural 

FTE 2 3 

Type Providers Assigned PCP 

NP 

LCSW 

PCP 

NP 

PA 

LCSW 

Ancillary Staff Assigned RN 

LPN 

Health/Medical 

Technician or Assistant 

RN 

LPN 

Pharmacist 

Health/Medical 

Technician or Assistant 

Type of MH Providers NP/Clinical Nurse Specialist 

LCSW 

PCP 

LCSW 

Provides MH Services Yes Yes 

 Evening Hours No No 

 Weekends No No 

 Plan for Emergencies 

Outside of Business Hours 

Yes Yes 

 Provided Onsite Substance Use Disorder 

PTSD 

MST 

Homelessness 

Psychosocial 

Rehabilitation 

Substance Use Disorder 

PTSD 

MST 

Homelessness 

Psychosocial 

Rehabilitation 

 Referrals Another VA facility 

Non-VA fee-basis or 

contract 

Another VA facility 

Non-VA fee-basis or 

contract 

 Tele-Mental Health Services Yes (Medication management, 

individual therapy) 

Yes (Medication management, 

individual therapy 

Remote Services Tele-Medicine Tele-Medicine 

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 Laboratory (Blood drawn) 

EKG 

Laboratory (Blood drawn) 

EKG 

Miles to Parent Facility 45 210 

Table 13: CBOC Characteristics 

VA OIG Office of Healthcare Inspections 18 
 

 

Spring City, Springfield, Sarasota, Sebring, Paragould, Salem, Cottonwood, and Lake Havasu City 

Quality of Care Measures 

DM 

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

diabetic retinopathy causes 12,000–24,000 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 14 displays 

the parent facility and the Cottonwood and Lake Havasu City CBOCs’ compliance in 

screening for retinopathy. 

Measure 

Meets 

Target Facility 

Qtr 3 

Numerator 

Qtr 3 

Denominator 

Qtr 3 

(%) 

DM – Retinal Eye 

Exam 

70% 649 NAVAHCS 55 57 96 

649GE Cottonwood CBOC 45 47 96 

649GC Lake Havasu City CBOC 40 44 91 

Table 14. 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 15 displays the scores of the 

parent facility and the Cottonwood and Lake Havasu City CBOCs. 

Measure 

Meets 

Target Facility 

Qtr 3 

Numerator 

Qtr 3 

Denominator 

Qtr 3 

(%) 

DM –A1c > 9 or not 

done in past year 

25% 649 NAVAHCS 8 57 14 

649GE Cottonwood CBOC 8 47 17 

649GC Lake Havasu City 

CBOC 

7 44 16 

Table 15. 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 

VA OIG Office of Healthcare Inspections 19 
Spring City, Springfield, Sarasota, Sebring, Paragould, Salem, Cottonwood, and Lake Havasu City 

older. Comparisons of the Cottonwood and Lake Havasu City CBOCs to the parent 

facility’s breast cancer screening are listed in Table 16. 

Measure 

Meets 

Target Facility 

Qtr 3 

Numerator 

Qtr 3 

Denominator 

Qtr 3 

(%) 

Mammography, 

50-69 years old 

77% 649 NAVAHCS 26 30 86 

649GE Cottonwood CBOC 9 10 90 

649GC Lake Havasu City 

CBOC 

3 5 60 

Table 16. Women’s Health, FY 2010 

Inquiries to the Lake Havasu City CBOC low scores revealed that mammograms were 

obtained for the patients through a fee basis agreement. Managers reported that the 

patients either did not schedule an appointment after the fee basis was approved or did 

not keep the scheduled appointment. We were informed that clinicians will be reminded 

to follow-up on all mammography referrals. 

C&P 

We reviewed the C&P files of two providers and the personnel folders of three nurses at 

the Cottonwood CBOC and four providers and three nurses at the Lake Havasu City 

CBOC. All providers possessed a full, active, current, and unrestricted license; and 

privileges were appropriate for services rendered. All nurses’ licenses 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 minimum 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 identified the 

following areas that needed improvement. 

VA OIG Office of Healthcare Inspections 20 
Spring City, Springfield, Sarasota, Sebring, Paragould, Salem, Cottonwood, and Lake Havasu City 

Critical Laboratory Results 

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

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

reviewed the medical records of 17 patients (9 at the Cottonwood CBOC and 8 at the 

Lake Havasu City CBOC) who had critical laboratory results and found that 

7 (78 percent) records contained documented evidence of patient notification and 

follow-up actions at the Cottonwood CBOC. Patients who had critical laboratory results 

at the Lake Havasu City CBOC were notified of their test results and provided 

appropriate follow-up instructions. 

Recommendation 13: We recommended that the ordering providers document patient 

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

CBOC. 

Normal Laboratory Results 

We found that the Lake Havasu City CBOC did not have consistent processes in place 

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

records of 20 patients (10 at the Cottonwood CBOC and 10 at the Lake Havasu City 

CBOC) and determined that the Lake Havasu City CBOC had not communicated 

normal test results to 5 (50 percent) of the patients within 14 calendar days from the 

date the results were available to the ordering provider. The Cottonwood CBOC 

notified patients (90 percent) of normal test results. 

Recommendation 14: We recommended that normal test results at the Lake Havasu 

City CBOC be communicated to patients within the specified timeframe. 

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. However, we found the following areas that needed 

improvement. 

IT Security 

We did not find a sign-in/out log to track individuals who accessed the IT area at the 

Cottonwood CBOC. At both CBOCs we found inappropriate IT equipment storage and 

security issues. The rooms containing IT equipment were unlocked, and there were 

several non-IT related items on floors. 

VA Handbook 650011 requires that access to areas that contain equipment or 

information critical to IT infrastructure be limited to authorized personnel. All entrances 

11 VA Handbook 6500, Information Security Program, August 4, 2006. 

VA OIG Office of Healthcare Inspections 21 
Spring City, Springfield, Sarasota, Sebring, Paragould, Salem, Cottonwood, and Lake Havasu City 

to sensitive areas will have a sign-in/out log for tracking individuals entering these 

areas. Entrance doors to these areas shall remain locked, unless necessary to open for 

deliveries or maintenance of equipment. 

Panic Alarms 

Both CBOCs provide MH services but did not have panic alarms for either the 

administrative or the clinical staff. The staff indicated that if they felt threatened and 

needed assistance, they would call out for help and try to leave the room. The parent 

facility conducted a vulnerability risk assessment and recommended the installation of a 

panic alarm system at each CBOC; however, no action for the installation of an alarm 

system had been implemented at the time of our inspection. 

Auditory Privacy 

The auditory privacy was inadequate for patients during the check-in process at the 

Cottonwood CBOC. VA Handbook 1605.1412 requires auditory privacy when staff 

discuss sensitive patient issues. Patients communicate with staff through an open 

reception area in the waiting area and are asked to provide, at a minimum, their name 

and the last four digits of their SSN. There were no instructions to incoming patients to 

allow patients at the window a zone of audible privacy during the check-in process. 

Recommendation 15: We recommended that the Chief of OI&T evaluate identified IT 

security vulnerabilities at the Cottonwood and Lake Havasu City CBOCs and implement 

appropriate IT security measures to ensure compliance with VA Handbook 6500. 

Recommendation 16: We recommended that panic alarm systems be installed at the 

Cottonwood and Lake Havasu City CBOCs. 

Recommendation 17: We recommended that the auditory privacy be maintained 

during the check-in process at the Cottonwood CBOC. 

Emergency Management 

Neither CBOC had policies or SOPs to instruct staff on how they should respond if a 

patient presented with a cardiac arrest, hypoglycemic event, and/or MH issues, among 

other medical emergencies. VHA Handbook 1006.1 requires each CBOC to have a 

local policy or SOP defining how medical emergencies, including MH, are handled. 

Recommendation 18: We recommended that a local policy or SOP for responding to 

medical and MH emergencies be developed for the Cottonwood and Lake Havasu City 

CBOCs. 

12 VHA Handbook 1605.1, Privacy and Release of Information, May 17, 2006. 

VA OIG Office of Healthcare Inspections 22 
Spring City, Springfield, Sarasota, Sebring, Paragould, Salem, Cottonwood, and Lake Havasu City 

Appendix A 

VISN 4 Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: February 4, 2011 

From: Director, VISN 4 (10N4) 

Subject: CBOC Review: Spring City and Springfield, PA 

To: Director, Baltimore Healthcare Inspections Division (54BA) 

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

I have reviewed the draft report of the Coatesville VA Medical Center 

CBOCs. I concur with the findings and recommendations. 

(original signed by:) 

MICHAEL E. MORELAND, FACHE 

VA OIG Office of Healthcare Inspections 23 
Spring City, Springfield, Sarasota, Sebring, Paragould, Salem, Cottonwood, and Lake Havasu City 

Appendix B 

Coatesville VAMC Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: February 3, 2011 

From: Director, Coatesville VAMC (542/00) 

Subject: CBOC Review: Spring City and Springfield, PA 

To: Director, VISN 4 (10N4) 

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

Coatesville VA Medical Center CBOCs. We concur with the findings and 

recommendations. 

2. I appreciate the opportunity for this review as a continuing process to 

improve care to our Veterans. 

Gary W. Devansky 

VA OIG Office of Healthcare Inspections 24 
Spring City, Springfield, Sarasota, Sebring, Paragould, Salem, Cottonwood, and Lake Havasu City 

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 the entrance be modified to improve
 

access for disabled veterans at the Springfield CBOC.
 

Concur
 

Target date for completion: March 31, 2011 (this is due to the time constraints of the
 

leased contractor).
 

Action Plan: Work order to install a doorbell has been entered. The expectation to staff
 

at the CBOC will be established that the doorbell is answered in a timely manner to
 

assist patients with entering the clinic.
 

Recommendation 2. We recommended that a procedure for monitoring and testing
 

panic alarms be developed for the Spring City CBOC.
 

Concur
 

Target date for completion: February 28, 2011
 

Action Plan: Staff will test their personal body panic alarms monthly. This will be
 

reported to the Primary Care Business office by the last day of each month. The testing
 

report will be reviewed monthly at the Primary Care Executive meeting.
 

Recommendation 3. We recommended that data for hand hygiene is collected and
 

monitored for the Spring City and Springfield CBOCs.
 

Concur
 

Target date for completion: March 31, 2011
 

Action Plan: Direct observation data is collected monthly by hand hygiene observers.
 

This was implemented on November 1, 2010. Data is given to Infection Control monthly 

for review, analysis and reporting at the Infection Control committee. Hand Hygiene 

survey is being developed to be used in conjunction with direct observation. 

VA OIG Office of Healthcare Inspections 25 
Spring City, Springfield, Sarasota, Sebring, Paragould, Salem, Cottonwood, and Lake Havasu City 

Appendix C 

VISN 8 Director Comments 

Department of 

Veterans Affairs Memorandum 

Date:	 February 7, 2011 

From:	 Director, VISN 8 (10N8) 

Subject:	 CBOC Review: Sarasota and Sebring, FL 

To:	 Director, Kansas City Healthcare Inspections Division 

(54KC) 

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

1. The recommendations made during the Office of Inspector 

General (OIG) Community Based Outpatient Clinic (CBOC) 

Reviews of Sarasota and Sebring, FL conducted 

November 15-19, 2010, have been reviewed and the facility 

implementation plan is provided. 

2. If you have any questions or require additional information, 

please do not hesitate to contact my office. 

Nevin M. Weaver 

VA OIG Office of Healthcare Inspections 26 
Spring City, Springfield, Sarasota, Sebring, Paragould, Salem, Cottonwood, and Lake Havasu City 

Appendix D 

Bay Pines HCS Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: February 4, 2011 

From: Director, Bay Pines HCS (516/00) 

Subject: CBOC Review: Sarasota and Sebring, FL 

To: Director, VISN 8 (10N8) 

1. The recommendations made during the Office of Inspector 

General (OIG) Community Based Outpatient Clinic (CBOC) 

Reviews of Sarasota and Sebring, FL conducted 

November 15-19, 2010, have been reviewed and our 

comments and implementation plan are noted below. 

2. I would like to thank the OIG CBOC Review Team for their 

professionalism and consultative feedback to our employees 

during our review. This review provides us with the 

opportunity to continue improving care to our Veterans. 

3. If you have any questions or require additional 

information, please contact Joanna Eastman-Gaudreau, 

Risk Manager, at 727-398-9317. 

WALLACE M. HOPKINS, FACHE
 

VA OIG Office of Healthcare Inspections 27 
Spring City, Springfield, Sarasota, Sebring, Paragould, Salem, Cottonwood, and Lake Havasu City 

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 hand hygiene data be collected, 

analyzed, and reported at the Sarasota and Sebring CBOCs. 

Concur 

Target date for completion: March 31, 2011 

Hand hygiene monitoring is presently performed by IC staff as well as staff who have 

been trained to observe and collect data. Hand Hygiene data is submitted to IC on a 

monthly basis. Staff at each CBOC have now been trained to perform this monitoring 

activity. The data is analyzed monthly by IC, and then the analysis is reported at least 

quarterly to the IC Committee. Trended and analyzed reports for Quarter 2 will be sent 

to key personnel at the CBOC’s at the end of the quarter and at least quarterly 

thereafter for their review and further action, as applicable. 

Recommendation 5. We recommended installation of signage to identify the location 

of fire extinguishers at the Sarasota and Sebring CBOCs. 

Concur 

Target date for completion: Completed 

Fire extinguisher locator signs were ordered to facilitate staff, patients, and visitors to 

quickly indentify the location of all fire extinguishers in the CBOCs. The new signage 

has been installed at the Sarasota and Sebring CBOCs. 

Recommendation 6. We recommended that access for disabled veterans be improved 

at the Sebring CBOC. 

Concur 

Target date for completion: Completed 

An assessment of the entrance way to the Sebring CBOC was completed. A wireless 

Video Doorbell with Intercom was ordered and received. Special assistance signage 

stating “If you are experiencing difficulty entering the clinic, ring doorbell for assistance.” 

was ordered and received. The new Video Doorbell with Intercom and the new signage 

have been installed. The Sebring CBOC staff have been instructed on this safety 

practice and are available to assist Veterans if needed. 

VA OIG Office of Healthcare Inspections 28 
Spring City, Springfield, Sarasota, Sebring, Paragould, Salem, Cottonwood, and Lake Havasu City 

Recommendation 7. We recommended revising the local policy for medical and MH 

emergencies to reflect the current practice and capability at the Sarasota CBOC. 

Concur 

Target date for completion: February 28, 2011 

The existing clinic Emergency Operations Plan for medical and MH emergencies, to 

include the management of violent behavior, is being revised to delineate the use of 

automatic external defibrillators and the notification system for mental health 

emergencies. Staff training will be completed following the revision of the policy. 

VA OIG Office of Healthcare Inspections 29 
Spring City, Springfield, Sarasota, Sebring, Paragould, Salem, Cottonwood, and Lake Havasu City 

Appendix E 

VISN 15 Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: February 11, 2011 

From: Director, VISN 15 (10N15) 

Subject: CBOC Reviews: Paragould, AR and Salem, MO 

To: Director, St. Petersburg Healthcare Inspections Division 

(54SP) 

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

I have reviewed the recommendations and concur with the response and 

action plans. If you have any questions, please contact our office at 

816.701.3000. 

(original signed by Acting Network Director for:) 

JAMES R. FLOYD, FACHE 

VA OIG Office of Healthcare Inspections 30 
Spring City, Springfield, Sarasota, Sebring, Paragould, Salem, Cottonwood, and Lake Havasu City 

Appendix F 

John J. Pershing VAMC Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: February 11, 2011 

From: Director, John J. Pershing VAMC (657/00) 

Subject: CBOC Reviews: Paragould, AR and Salem, MO 

To: Director, VISN 15 (10N15) 

1.	 We appreciate the opportunity to review the draft report for the John J. 

Pershing VA Medical Center in Poplar Bluff, Missouri. 

2.	 Attached, please find Poplar Bluff VA Medical Center’s response to the Office 

of Inspector General Community Based Outpatient Clinic (CBOC) review 

conducted during the week of November 15, 2010. 

3.	 We would like to extend our appreciation to the Office of Inspector General 

Team that conducted the review; they were very professional and provided 

excellent feedback to our staff. We appreciate their thorough review and the 

opportunity to further improve the quality care we provide to our Veterans 

every day. 

4.	 If you have any questions regarding the information provided, please contact 

Dawna Bader, Director of Performance Improvement. Ms. Bader can be 

reached at (573) 778-4280. 

(original signed by:) 

GLENN A. COSTIE, FACHE 

Medical Center Director 

VA OIG Office of Healthcare Inspections 31 
Spring City, Springfield, Sarasota, Sebring, Paragould, Salem, Cottonwood, and Lake Havasu City 

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 8. We recommended that normal test results be communicated to 

patients within the specified timeframe at the Paragould CBOC. 

Concur 

Target date for completion: March 31, 2011 

A new process was implemented in December 2011 in a Primary Care test clinic 

whereby a Primary Care team member (clerk or LPN) is notified by view alert to the 

normal labs and radiology results. Once the alert is received, the PC team member 

initiates and sends a letter of notification to the Veteran of his/her normal test results 

and documents this action in the electronic health record. So far, this process has been 

effective in the test clinic and will be rolled out to the remaining Primary Care clinics by 

March 31, 2011. Afterwards, a monthly chart review will be performed for every clinic 

and results reported through the Medical Records Committee until the target of 90% is 

achieved and sustained, after which the review will be conducted quarterly. 

Recommendation 9. We recommended that hand hygiene data is collected, analyzed, 

and reported for the Paragould and Salem CBOCs. 

Concur 

Target date for completion: Completed February 2, 2011 

An Infection Control (IC) Champion has been identified from both the Paragould and 

Salem CBOCs. Education on hand hygiene data collection was provided to both the 

Champions and staff. Using a “secret shopper” technique, data is collected monthly by 

the IC Champion and sent to Infection Control Nurse. These data are then analyzed 

and graphed, and aggregate data submitted monthly to the Clinical Safety Committee 

along with recommendations for improvement as indicated. Data collection for 

Paragould CBOC began in July 2010; data for Salem CBOC began in October 2010. 

During this review period, Paragould CBOC’s hand hygiene compliance has averaged 

94% and Salem’s CBOC’s compliance has averaged 100%. Results from these Hand 

Hygiene monitors are reported to the Clinical Safety Committee on a monthly basis. 

Because average compliance rates are > 90%, recommend closure of this item. 

Recommendation 10. We recommended that fire drills be conducted at the Salem 

CBOC as required by NFPA. 

Concur 

VA OIG Office of Healthcare Inspections 32 
Spring City, Springfield, Sarasota, Sebring, Paragould, Salem, Cottonwood, and Lake Havasu City 

Target date for completion: April 1, 2011 

The facility is in the process or updating the Salem CBOC Lease Agreement, and the 

language in the agreement requires the leasor to conduct annual fire drills. In addition, 

a fire drill will be conducted during one of the facility’s two Environment of Care (EOC) 

semi-annual inspection visits. 

Recommendation 11. We recommended that VA directives and guidelines for real 

property lease agreements are followed. 

Concur 

Target date for completion: April 1, 2011 

The VISN 15 contracting group and the COTR for the Salem CBOC are updating the 

Salem lease agreement to include all VA requirements related to real property lease 

agreements. It is anticipated that this will be completed prior to April 1, 2011. 

Recommendation 12. We recommended that VA enter into a contract to perform 

laboratory and other medical services for VA at negotiated prices, or if a contract is not 

beneficial to the VA, then the Facility Director must ensure that VA directives and 

guidelines for fee basis care are followed. 

Concur 

Target date for completion: April 1, 2011 

A review of the benefits verses the costs for a contract for laboratory and /or radiology 

services with the Salem Hospital has been completed. It has been determined that there 

is no financial benefit for such a contract as the facility only pays Medicare costs at this 

time. Each patients needs are being evaluated on a case-by-case basis for the need for 

fee services related to laboratory services or other medical services. VHA fee 

regulations and guidelines will be followed to ensure the appropriate process is 

followed. In addition an MOU is being developed with the Salem Hospital related to 

laboratory and radiology services for patients receiving care at the Salem CBOC which 

is housed on hospital property, with an anticipated completion date of April 1, 2011. 

VA OIG Office of Healthcare Inspections 33 
Spring City, Springfield, Sarasota, Sebring, Paragould, Salem, Cottonwood, and Lake Havasu City 

Appendix G 

VISN 18 Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: February 7, 2011 

From: Network Director, VISN 18 (10N18) 

Subject: CBOC Reviews: Cottonwood and Lake Havasu City, AZ 

To: Director, Los Angeles Healthcare Inspections Division 

(54LA)
 

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

I. I concur with the attached facility response to the recommendations for 

improvement contained in the CBOC Reviews: Cottonwood and Lake 

Havasu City, AZ report. 

2. If you have additional questions or concerns, please contact 

Sally Compton, VISN 18 Executive Assistant to the Network Director, at 

(602) 222-2699. 

(original signed by:) 

Susan P. Bowers 

VA OIG Office of Healthcare Inspections 34 
Spring City, Springfield, Sarasota, Sebring, Paragould, Salem, Cottonwood, and Lake Havasu City 

Appendix H 

Northern Arizona VA HCS Interim Director Comments 

Department of 

Veterans Affairs Memorandum 

Date:	 February 1, 2011 

From:	 Interim Director, Northern Arizona VA Health Care System 

(649/00) 

Subject:	 CBOC Reviews: Cottonwood and Lake Havasu City, AZ 

To:	 Director, VISN 18 (10N18) 

1.	 I have reviewed and concur with the findings and recommendations by 

the Office of the Inspector General in their review of the Community 

Based Outpatient Clinics at Cottonwood and Lake Havasu City, 

Arizona. 

2.	 Corrective action plans have been established with target completion 

dates, as detailed in the attached report. 

Wendy J. Hepker, FACHE 

VA OIG Office of Healthcare Inspections 35 
Spring City, Springfield, Sarasota, Sebring, Paragould, Salem, Cottonwood, and Lake Havasu City 

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 13. We recommended that the ordering providers document patient 

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

CBOC. 

Concur 

Target date for completion: April 8, 2011 

Planned Action: To ensure that ordering providers document patient notification and 

treatment actions in response to critical results, the following actions are being taken. 

The ordering provider (or the provider receiving the critical results) will document 

acknowledgement of receipt of the critical result, her/his assessment and plan, and 

patient notification in the Computerized Patient Record System (CPRS). The elements 

of documentation and template use will be communicated to all ordering/receiving 

providers with training completed and fully implemented by April 8, 2011. The 

documentation elements will be monitored and reported to the Medical Executive Board 

using monthly chart audits conducted by the Primary Care Service Line Manager using 

a sample of 10 records/month, or 100% if the number of critical results is less than 

10/month, until a benchmark of 90% is achieved. After three months of achieving the 

benchmark, review and reporting of the documentation elements will continue quarterly 

for one year. 

Recommendation 14. We recommended that normal test results at the Lake Havasu 

City CBOC be communicated to patients within the specified timeframe. 

Concur 

Target date for completion: April 8, 2011 

Planned Action: To ensure that normal test results at the Lake Havasu City CBOC are 

communicated to patients within the specified timeframe, the following actions are being 

taken. Primary Care Service Line Standard Operating Procedure (SOP), Reporting 

Test Results, outlines responsibilities and process of notification of all lab results to 

patients. The elements of documentation and template to be used will be 

communicated to all ordering providers with training completed and fully implemented 

by April 8, 2011. The documentation elements will be monitored and reported to the 

Medical Executive Board using monthly chart audits conducted by the Primary Care 

Service Line Manager using a sample of 10 records/month until a benchmark of 90% is 

achieved. After three months of achieving the benchmark, review and reporting of the 

documentation elements will continue quarterly for one year. 

VA OIG Office of Healthcare Inspections 36 
Spring City, Springfield, Sarasota, Sebring, Paragould, Salem, Cottonwood, and Lake Havasu City 

Recommendation 15. We recommended that the Chief of OI&T evaluate identified IT 

security vulnerabilities at the Cottonwood and Lake Havasu CBOCs and implement 

appropriate IT security measures to ensure compliance with VA Handbook 6500. 

Concur 

Target date for completion: April 30, 2011 

Planned Action: To ensure that IT security vulnerabilities at the Cottonwood and Lake 

Havasu City CBOCs are identified and appropriate IT security measures that meet 

compliance with VA Handbook 6500 are implemented, the following actions are being 

taken. Chief of OI&T will review current NAVAHCS Health Care System Memorada 

(HCSM) related to access of the IT areas at the Cottonwood and Lake Havasu City 

CBOCs and will make revisions to assure compliance with VA Handbook 6500. The 

CBOC Nurse Manager and CBOC Supervisors will provide training to all CBOC staff 

regarding appropriate IT security measures and use of the Telecommunications Sign-In 

Sheet. Use and completion of the sign-in sheet will be monitored by the CBOC 

Manager and reported to the Chief of OI&T on a quarterly basis for one year. This will 

also be monitored on Environment of Care (EOC) security rounds with results submitted 

to EOC website; a monthly summary of EOC Rounds is reported by the Safety Manager 

at the Environment of Care Board (EOCB). 

Recommendation 16. We recommended that panic alarm systems be installed at the 

Cottonwood and Lake Havasu City CBOCs. 

Concur 

Target date for completion: March 1, 2011 

Planned Action: To provide safety and assistance for staff, the following actions have 

been taken. Panic alarm systems have been installed at Lake Havasu and Cottonwood 

CBOCs. The CBOC Nurse Manager and CBOC Supervisors have provided training to 

all CBOC staff regarding the panic alarm system. Monthly testing of the alarm system 

will be conducted by the CBOC Medical Services Assistant (MSA) and a report will be 

submitted monthly to NAVAHCS Police. NAVAHCS HCSM PD-48, Panic Alarms, will 

be updated to include CBOC panic alarm information and responsibility. 

Recommendation 17. We recommended that the auditory privacy be maintained 

during the check-in process at the Cottonwood CBOC. 

Concur 

Target date for completion: Completed 

Planned Action: To ensure that auditory privacy is maintained at the Cottonwood 

CBOC, the following actions have been taken. Signage has been posted at the checkin area which reads “Please respect the privacy of others. Wait until you are called 

before approaching the counter.” The CBOC Nurse Manager and CBOC Supervisor 

VA OIG Office of Healthcare Inspections 37 
Spring City, Springfield, Sarasota, Sebring, Paragould, Salem, Cottonwood, and Lake Havasu City 

have provided training to the CBOC staff regarding auditory privacy. Compliance with 

auditory privacy will be monitored by the Cottonwood CBOC Supervisor and reported to 

the EOCB on a quarterly basis for one year. This will also be monitored on EOC 

Privacy rounds with results submitted to EOC website; a monthly summary of EOC 

Rounds is reported by the Safety Manager at EOCB. 

Recommendation 18. We recommended that a local policy or SOP for responding to 

medical and MH emergencies be developed for the Cottonwood and Lake Havasu City 

CBOCs. 

Concur 

Target date for completion: March 1, 2011 

Planned Action: To ensure that staff responds appropriately when a patient presents 

with an emergent condition including cardiac arrest, hypoglycemic event, and/or Mental 

Health issues, the following actions have been taken. A new SOP, CBOC Emergency 

Operations Plan, was developed in accordance with VHA Handbook 1006.1. The 

CBOC Nurse Manager and individual CBOC Supervisors have provided training to all 

CBOC staff regarding the new SOP. 

VA OIG Office of Healthcare Inspections 38 
Spring City, Springfield, Sarasota, Sebring, Paragould, Salem, Cottonwood, and Lake Havasu City 

Appendix I 

OIG Contact and Staff Acknowledgments 

Contact for	 Donald Braman 

Spring City and Baltimore Office of Healthcare Inspections 

Springfield 

(VISN 4) 

Contact for James Seitz 

Sarasota and Kansas City Office of Healthcare Inspections 

Sebring (VISN 8) 

Contact for Annette Robinson 

Paragould and St. Petersburg Office of Healthcare Inspections 

Salem (VISN 15) 

Contact for Daisy Arugay, Director 

Cottonwood and Los Angeles Office of Healthcare Inspections 

Lake Havasu 

City (VISN 18) 

Contributors	 Douglas Henao, RD 

Sheila Bezak, RN 

Shirley Carlile, BA 

Jennifer Christenson, DPM 

Lin Clegg, Ph.D. 

Myra Conway, RN 

Marnette Dhooghe, MS 

Stephanie Hills, RN 

Deborah Howard, RN 

Sandra Khan, RN 

Judy Montano, MS 

Reba B. Ransom, RN 

Simonette Reyes, RN 

Kathleen Shimoda, RN 

Mary Toy, RN 

Jennifer Whitehead 

VA OIG Office of Healthcare Inspections 39 
Spring City, Springfield, Sarasota, Sebring, Paragould, Salem, Cottonwood, and Lake Havasu City 

Appendix J 

Report Distribution 

VA Distribution 

Office of the Secretary
 

Veterans Health Administration
 

Assistant Secretaries
 

General Counsel
 

Director, VISN 4 (10N4)
 

Director, Coatesville VAMC (542/00)
 

Director, VISN 8 (10N8)
 

Director, Bay Pines HCS (516/00)
 

Director, VISN 15 (10N15)
 

Director, John J. Pershing VAMC (657/00)
 

Director, VISN 18 (10N18)
 

Interim Director, Northern Arizona VA HCS (649/00)
 

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: Roy Blunt, John Boozman, Robert P. Casey, Jr., Jon Kyl, John McCain, 

Claire McCaskill, Bill Nelson, Mark L. Pryor, Marco Rubio, Patrick J. Toomey 

U.S. House of Representatives: Gus M. Bilirakis, Vern Buchanan, Kathy Castor, Rick 

Crawford, Jo Ann Emerson, Jeff Flake, Trent Franks, Jim Gerlach, Gabrielle Giffords, 

Paul A. Gosar, Raul M. Grijalva, Connie Mack, Patrick Meehan, Ed Pastor, Joseph 

Pitts, Benjamin Quayle, Thomas J. Rooney, David Schweikert, C.W. Bill Young 

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

VA OIG Office of Healthcare Inspections 40