Department of Veterans Affairs 

Office of Inspector General 

Office of Healthcare Inspections
 

Report No.10-02991-96 

Combined Assessment Program
 

Review of the
 

Coatesville VA Medical Center
 

Coatesville, Pennsylvania
 

February 23, 2011 

Washington, DC 20420
 
Why We Did This Review 

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

General's (OIG's) efforts to ensure that high quality health care is provided to our 

Nation's veterans. CAP reviews combine the knowledge and skills of the OIG's Offices 

of Healthcare Inspections and Investigations to provide collaborative assessments of 

VA medical facilities on a cyclical basis. The purposes of CAP reviews are to: 

 Evaluate how well VA facilities are accomplishing their missions of providing veterans 

convenient access to high quality medical services. 

 Provide crime awareness briefings to increase employee understanding of the 

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

the OIG. 

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

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

To Report Suspected Wrongdoing in VA Programs and Operations 

Telephone: 1-800-488-8244 

E-Mail: vaoighotline@va.gov 

(Hotline Information: http://www.va.gov/oig/contacts/hotline.asp) 
CAP Review of the Coatesville VA Medical Center, Coatesville, PA 

Glossary 

C&P credentialing and privileging 

CAP Combined Assessment Program 

CHF congestive heart failure 

CLC community living center 

COC coordination of care 

CRC community residential care 

EOC environment of care 

facility Coatesville VA Medical Center 

FY fiscal year 

JC Joint Commission 

MDRO multidrug-resistant organisms 

MH mental health 

MSIT Multidisciplinary Safety Inspection Team 

OIG Office of Inspector General 

OSHA Occupational Safety and Health Administration 

QM quality management 

UC urgent care 

VHA Veterans Health Administration 

VISN Veterans Integrated Service Network 

VA OIG Office of Healthcare Inspections 
CAP Review of the Coatesville VA Medical Center, Coatesville, PA 

Table of Contents 

Page
 

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

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

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

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

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

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

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

EOC................................................................................................................... 2
 

Physician C&P................................................................................................... 4
 

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

Management of MDRO...................................................................................... 5
 

Review Activities Without Recommendations ......................................................... 6
 

COC .................................................................................................................. 6
 

QM..................................................................................................................... 6
 

Comments................................................................................................................... 6
 

Appendixes 

A. Facility Profile .................................................................................................... 7
 

B. Follow-Up on Previous Recommendations........................................................ 8
 

C. VHA Satisfaction Surveys ................................................................................. 10
 

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

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

F. OIG Contact and Staff Acknowledgments ......................................................... 15
 

G. Report Distribution ............................................................................................ 16
 

VA OIG Office of Healthcare Inspections 
Executive Summary: Combined Assessment Program 

Review of the Coatesville VA Medical Center, Coatesville, PA 

Review Purpose: The purpose was 

to evaluate selected activities, focusing 

on patient care administration and 

quality management, and to provide 

crime awareness training. We 

conducted the review the week of 

November 15, 2010. 

Review Results: The review covered 

six activities. We made no 

recommendations in the following 

activities: 

 Coordination of Care 

 Quality Management 

The facility’s reported accomplishments 

were the receipt of a Gold Cornerstone 

Award for patient safety and the 

production of a quick reference tri-fold 

for emergency preparedness. 

Recommendations: We made 

recommendations in the following four 

activities: 

Environment of Care: Conduct a 

comprehensive inspection of the facility, 

and take action to correct deficiencies 

related to patient safety, fire safety, 

general cleanliness, and maintenance. 

Complete and document N95 respirator 

fit testing and training for appropriate 

personnel. 

Physician Credentialing & Privileging: 

Strengthen processes to ensure that 

privilege documentation and approval 

comply with Veterans Health 

Administration requirements. 

Management of Test Results: 

Communicate normal test results to 

patients within the specified timeframe. 

Management of Multidrug-Resistant 

Organisms: Ensure employees receive 

annual multidrug-resistant organism 

education that includes training on the 

color-coded isolation precautions, and 

consistently document the training. 

Comments 

The Veterans Integrated Service 

Network and Facility Directors agreed 

with the Combined Assessment 

Program review findings and 

recommendations and provided 

acceptable improvement plans. We will 

follow up on the planned actions until 

they are completed.

 (original signed by:) 

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

Assistant Inspector General for
 

Healthcare Inspections
 

VA OIG Office of Healthcare Inspections i 
CAP Review of the Coatesville VA Medical Center, Coatesville, PA 

Objectives and Scope 

Objectives
 

Scope
 

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

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

services. The objectives of the CAP review are to: 

	 Conduct recurring evaluations of selected health care 

facility operations, focusing on patient care administration 

and QM. 

	 Provide crime awareness briefings to increase employee 

understanding of the potential for program fraud and the 

requirement to refer suspected criminal activity to the 

OIG. 

We reviewed selected clinical and administrative activities to 

evaluate the effectiveness of patient care administration and 

QM. Patient care administration is the process of planning 

and delivering patient care. QM is the process of monitoring 

the quality of care to identify and correct harmful and 

potentially harmful practices and conditions. 

In performing the review, we inspected selected areas, 

interviewed managers and employees, and reviewed clinical 

and administrative records. The review covered the 

following six activities: 

	 COC 

	 EOC 

	 Management of MDRO 

	 Management of Test Results 

	 Physician C&P 

	 QM 

The review covered facility operations for FY 2010 and 

FY 2011 through November 15, 2010, and was done in 

accordance with OIG standard operating procedures 

for CAP reviews. We also followed up on selected 

recommendations from our prior CAP review of the facility 

(Combined Assessment Program Review of the Coatesville 

VA Medical Center, Coatesville, Pennsylvania, Report 

No. 08-01089-137, June 4, 2008). The facility provided 

VA OIG Office of Healthcare Inspections 1 
CAP Review of the Coatesville VA Medical Center, Coatesville, PA 

sufficient proof that it had corrected all findings. (See 

Appendix B for further details.) 

During this review, we also presented crime awareness 

briefings for 332 employees. These briefings covered 

procedures for reporting suspected criminal activity to the 

OIG and included case-specific examples illustrating 

procurement fraud, conflicts of interest, and bribery. 

In this report, we make recommendations for improvement. 

Recommendations pertain to issues that are significant 

enough to be monitored by the OIG until corrective actions 

are implemented. 

Reported Accomplishments 

The facility received a Gold Cornerstone Award from the 

National Center for Patient Safety for the quality and number 

of root cause analyses completed during FY 2010. 

The facility produced quick reference tri-folds for emergency 

preparedness and placed them at critical access points 

throughout the facility. 

Gold Cornerstone 

Award 

Quick Reference 

Tri-folds 

Results 

Review Activities With Recommendations 

EOC	 The purpose of this review was to determine whether the 

facility maintained a safe and clean health care environment 

in accordance with applicable requirements. 

We inspected the locked MH, acute medical, and CLC units. 

We also inspected Physical Medicine and Rehabilitation 

Service, Radiology Service, primary care outpatient clinics, 

and the UC clinic. The facility maintained a generally safe 

environment. 

The Health Insurance Portability and Accountability Act 

requires confidential patient information to be secured. We 

found that some chairs in the UC clinic waiting room were 

too close to the reception desk to ensure auditory privacy for 

patients checking in. Staff immediately moved the chairs 

away from the reception desk while we were onsite. 

Therefore, we made no recommendation for this finding. 

However, we identified the following conditions that needed 

improvement. 

VA OIG Office of Healthcare Inspections 2 
CAP Review of the Coatesville VA Medical Center, Coatesville, PA 

Patient Safety. VHA requires that locked inpatient MH units 

be free of objects that could serve as anchor points for 

hanging.1 During our inspection of the locked MH unit, we 

identified the following hazards: 

 Some door closure mechanisms 

 Two payphones with cord lengths that exceeded 

12 inches 

 A shower safety grab bar 

 A patient room door handle 

While we were onsite, the facility devised a plan to address 

the hazards temporarily while pursuing options for a 

permanent solution. 

Fire Safety. National Fire Protection Association standards 

require that corridors be clear of obstructions in the event 

that emergency evacuation is required. We found medical 

equipment stored in a CLC hallway that reduced the corridor 

width to less than 6 feet and blocked the egress to an exit 

door. We also found the egress to a fire exit in the UC clinic 

obstructed. 

General Cleanliness and Maintenance. The JC requires that 

areas used by patients be clean. During our inspection of 

patient care areas, we noted general cleanliness and 

maintenance conditions needing improvement. In most 

areas, including housekeeping and utility closets, we found 

dirt and debris on floors, along baseboards, and in corners. 

Dust accumulation was visible on sprinkler heads, on air 

ventilation system covers, and on unsecured uninterruptible 

power supply units on the floor. We also observed holes in 

walls, stained ceiling tiles, warped walls, and buckled floor 

tiles in multiple areas. 

Two patient showers on the locked MH unit were in need of 

deep cleaning. We found a soiled shower curtain and 

evidence of live insects. Staff took immediate action to 

correct these deficiencies. We reinspected the shower area 

the next day and found it to be clean; however, ongoing 

monitoring of the area is needed. 

N95 Respirator Fit Testing.

2 OSHA standards require 

designated staff to be fit tested and trained for respirator use 

1 VHA National Center for Patient Safety, “Mental Health Environment of Care Checklist,” November 1, 2010. 

2 An N95 respirator mask provides protection through a tight facial seal and 95 percent filter efficiency. Although 

the "N" means “not resistant to oil,” they are fluid resistant. 

VA OIG Office of Healthcare Inspections 3 
CAP Review of the Coatesville VA Medical Center, Coatesville, PA 

Recommendations 

Physician C&P 

Recommendation 

Management of 

Test Results 

as part of a complete respiratory protection program. We 

reviewed 10 employee training records and determined that 

only 5 (50 percent) of the designated employees had 

received the required annual fit testing or training. 

1. We recommended that a comprehensive EOC 

inspection of the facility be conducted and that appropriate 

actions be taken to correct identified deficiencies related to 

patient safety, fire safety, general cleanliness, and 

maintenance. 

2. We recommended that annual N95 respirator fit testing 

and training be completed and documented for all 

designated employees. 

The purpose of this review was to determine whether the 

facility had consistent processes for physician C&P that 

complied with applicable requirements. 

We reviewed 12 physicians’ C&P files and profiles and found 

that licenses were current and that primary source 

verification had been obtained. However, we identified the 

following area that needed improvement. 

Privileges. VHA requires that privileges granted to a 

physician be time-limited and specific to the facility, service, 

setting, and provider.3 We reviewed the records of 

12 privileged physicians and found only 3 (25 percent) 

records without irregularities. Examples of irregularities 

included forms with missing or illegible documentation 

regarding the specific setting, service, or timeframe for 

privileges requested. Additionally, one physician was 

granted privileges when a required certification was in a 

pending status. 

3. We recommended that processes be strengthened to 

ensure that privilege documentation and approval comply 

with VHA requirements. 

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

review that identified improvement opportunities related to 

documentation of notification of abnormal test results and 

follow-up actions taken.4 

3 VHA Handbook 1100.19, Credentialing and Privileging, November 14, 2008.
 4 Healthcare Inspection Summary Review – Evaluation of Veterans Health Administration Procedures for
 

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

VA OIG Office of Healthcare Inspections 4 
CAP Review of the Coatesville VA Medical Center, Coatesville, PA 

We reviewed the facility’s policies and procedures, and we 

reviewed medical records. We identified the following area 

that needed improvement. 

Communication of Normal Results. VHA requires facilities to 

communicate normal test results to patients no later than 

14 calendar days from the date that the results were 

available to the ordering provider.5 We reviewed the medical 

records of 20 patients who had normal results and found that 

only 12 (60 percent) records contained documented 

evidence that the facility had communicated the results to the 

patients. 

Recommendation	 4. We recommended that normal test results be 

consistently communicated to patients within the specified 

timeframe. 

Management of	 The purpose of this review was to evaluate whether the facility 

MDRO had developed a safe and effective program to reduce the 

incidence of MDRO in its patient population in accordance 

with applicable requirements. 

We inspected the CLC (1BNH & 59B) and domiciliary 

(8BDOM) units, interviewed six employees, and reviewed 

medical records and employee training records. We 

identified no deficits in either the inspections or the medical 

records. However, we identified the following area that 

needed improvement. 

Employee Training. The JC requires that facilities conduct a 

risk assessment to determine the need for staff education. 

The facility’s most recent risk assessment stated that 

education was indicated for all employees during orientation 

and annually thereafter. The facility has a color-coded 

system in which colored dots are used outside patients’ 

rooms to identify precautions appropriate to the type of 

isolation. We reviewed 10 employee-training records and 

found only 1 (10 percent) record with documentation 

regarding the color-coded isolation precautions. Additionally, 

we interviewed six employees, and none could state the 

isolation precautions related to the color codes. 

Recommendation	 5. We recommended that employees receive annual 

MDRO training that includes the color-coded isolation 

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

VA OIG Office of Healthcare Inspections 5 
CAP Review of the Coatesville VA Medical Center, Coatesville, PA 

precautions and that the training be consistently 

documented. 

Review Activities Without Recommendations 

COC	 The purpose of this review was to evaluate whether the 

facility managed advance care planning, advance directives, 

and discharges in accordance with applicable requirements. 

We reviewed patients’ medical records and determined that 

the facility generally met requirements in these areas. We 

made no recommendations. 

QM	 The purpose of this review was to evaluate whether the 

facility had a comprehensive QM program in accordance with 

applicable requirements and whether senior managers 

actively supported the program’s activities. 

We interviewed senior managers and QM personnel, and we 

evaluated policies, meeting minutes, and other relevant 

documents. The QM program was generally compliant with 

requirements, and senior managers supported the program. 

We made no recommendations. 

Comments 

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

recommendations and provided acceptable improvement plans. (See Appendixes D 

and E, pages 11–14, for the full text of the Directors’ comments.) We consider 

Recommendation 4 closed. We will follow up on the planned actions for the open 

recommendations until they are completed. 

VA OIG Office of Healthcare Inspections 6 
CAP Review of the Coatesville VA Medical Center Coatesville, PA 

Appendix A 

Facility Profile6 

Type of Organization Specialty referral 

Complexity Level 3 

VISN 4 

Community Based Outpatient Clinics Spring City, PA 

Springfield, PA 

Veteran Population in Catchment Area 373,738 

Type and Number of Total Operating Beds: 

 Hospital, including Psychosocial 

Residential Rehabilitation Program 

306 

 CLC/Nursing Home Care Unit 169 



Medical School Affiliation(s) Drexel University 

 Number of Residents 6 

FY 2010 Prior FY (2009) 

Resources (in millions): 

 Total Medical Care Budget $174 $172 

 Medical Care Expenditures $138 $171 

Total Medical Care Full-Time Employee 

Equivalents 

1,321 1,302.4 

Workload: 

 Number of Station Level Unique 

Patients 

19,077 19,007 

 Inpatient Days of Care: 

o Acute Care (Medicine) 163 225 

o Acute Care (Psychiatry 58B) 8,721 10,552 

o CLC/Nursing Home Care Unit 47,676 48,047 

Hospital Discharges 2,847 2,961 

Total Average Daily Census (including all bed 

types) 

409 405 

Cumulative Occupancy Rate 86% 85% 

Outpatient Visits 169,530 175,309 

6 All data provided by facility management. 

VA OIG Office of Healthcare Inspections 7 
CAP Review of the Coatesville VA Medical Center, Coatesville, PA 

Appendix B 

Follow-Up on Previous Recommendations 

Recommendations Current Status of Corrective Actions 

Taken 

In 

Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

CRC Program 

1. Ensure that visits to CRC program homes 

are documented in the electronic medical 

record. 

Visits are being documented in the 

electronic medical record. 

Y N 

2. Ensure that the CRC Coordinator 

updates the CRC handbook annually and 

meets with CRC home operators annually to 

review the handbook and that these 

meetings are documented in the electronic 

medical record. 

The handbook is updated annually, 

and the Coordinator meets with home 

operators annually. 

Y N 

3. Ensure that the CRC Coordinator meets 

annually with VA Regional Office fiduciaries 

to discuss CRC residents and documents 

the meetings in the electronic medical 

record. 

The CRC Program Coordinator 

coordinates this on an annual basis. 

Y N 

QM 

4. Require the Peer Review Committee to 

meet at least quarterly. 

Meetings are held every quarter. Y N 

Pharmacy Operations 

5. Require that annual training for controlled 

substances inspectors is conducted and 

documented. 

This has been conducted and 

documented. 

Y N 

VA OIG Office of Healthcare Inspections 8 
CAP Review of the Coatesville VA Medical Center, Coatesville, PA 

Recommendations Current Status of Corrective Actions 

Taken 

In Compliance 

Y/N 

Repeat 

Recommendation? 

Y/N 

EOC 

6. Require that all designated EOC team 

members participate in all EOC rounds and 

that documentation of participation is 

complete. 

The EOC rounds policy has been 

revised to include required members 

and invited guests. 

Y N 

7. Comply with VHA policy regarding security 

measures for protection of research animals. 

The Research Associate Chief of Staff 

reviews and initials the sign-in sheets 

to ensure everyone is signing in and 

out of the building. 

Y N 

8. Ensure compliance with VHA patient safety 

standards for training of locked MH unit staff 

and MSIT members. Ensure that the MSIT 

includes the appropriate disciplines. 

MH EOC training is now recorded in 

the Learning Management System. 

There is a sign-in sheet for the rounds 

that includes the appropriate 

membership. 

Y N 

9. Require appropriate staffing of the UC 

clinic during all hours of operation. 

The UC clinic has 24/7 nursing staff. Y N 

VA OIG Office of Healthcare Inspections 9 
CAP Review of the Coatesville VA Medical Center, Coatesville, PA 

Appendix C 

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

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

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

quarters 1–3 of FY 2010. 

Table 1 

FY 2010 

(inpatient target = 64, outpatient target = 56) 

Inpatient 

Score 

Quarter 1 

Inpatient 

Score 

Quarter 2 

Inpatient 

Score 

Quarter 3 

Outpatient 

Score 

Quarter 1 

Outpatient 

Score 

Quarter 2 

Outpatient 

Score 

Quarter 3 

Facility    64.6 70.4 65.7 

VISN 62.7 65.5 65.3 59.5 61.4 60.1 

VHA 63.3 63.9 64.5 54.7 55.2 54.8 

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

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

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

0.0 

0.5 

1.0 

1.5 

2.0 

2.5 

3.0 

3.5 

4.0 

4.5 

5.0 

2008 2009 2010 

Facility 

VISN 

National 

VA ALL EMPLOYEE SURVEY 

OVERALL SATISFACTION Figure 1: 

LEVEL OF SATISFACTION 

 Not reported. Less than 30 responses. 

VA OIG Office of Healthcare Inspections 10 
CAP Review of the Coatesville VA Medical Center, Coatesville, PA 

Appendix D 

VISN Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: February 4, 2011
 

From: Director, VISN 4 (10N4)
 

Subject: CAP Review of the Coatesville VA Medical Center,
 

Coatesville, PA 

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

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

1.	 I have reviewed the submitted responses and concur with the findings 

and recommendations. 

(original signed by:) 

MICHAEL E. MORELAND, FACHE 

VA OIG Office of Healthcare Inspections 11 
CAP Review of the Coatesville VA Medical Center, Coatesville, PA 

Appendix E 

Facility Director Comments 

Department of 

Veterans Affairs Memorandum 

Date: February 3, 2011 

From: Director, Coatesville VA Medical Center (542/00) 

Subject: CAP Review of the 

Coatesville, PA 

Coatesville VA Medical Center, 

To: Director, VISN 4 (10N4) 

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

Assessment Program (CAP) of the Coatesville VA Medical Center. 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. 

(original signed by:) 

Gary W. Devansky 

VA OIG Office of Healthcare Inspections 12 
CAP Review of the Coatesville VA Medical Center, Coatesville, PA 

Comments to Office of Inspector General’s Report
 

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

in the Office of Inspector General report: 

OIG Recommendations 

Recommendation 1. We recommended that a comprehensive EOC inspection of the 

facility be conducted and that appropriate actions be taken to correct identified 

deficiencies related to patient safety, fire safety, general cleanliness, and maintenance. 

Concur 

Target date for completion: August 31, 2011 

Action Plan: This will be included in our weekly EOC rounds with an emphasis on 

completing all of the deficiencies as soon as possible. EOC rounds are conduct every 

Friday and it takes 6 months to do the entire facility once. This includes all areas, 

clinical and administrative. A report will be sent quarterly to Executive Leadership 

Council for review and recommendations. 

Recommendation 2. We recommended that annual N95 respirator fit testing and 

training be completed and documented for all designated employees. 

Concur 

Target date for completion: March 31, 2011 

Action Plan: Current roster has been updated. The Safety Officer will ensure that all 

staff fit testing is current. Area Business Managers send current staff roster to the 

Safety Officer monthly. New staff are immediately added to the fit testing roster and fit 

tested. Fit test data is recorded in Occupational Health Recording System, Porta Count 

machine data base, and a hard copy certificate is kept in the Safety Office. Current 

compliance rate is 8 percent. 

Recommendation 3. We recommended that processes be strengthened to ensure that 

privilege documentation and approval comply with VHA requirements. 

Concur 

Target date for completion: Completed. 

Action Plan: 

	 Any response, from an institution where a prospective appointee has practiced, 

that does not contain information about specific privilege competence, will be 

followed by a written request specifying what information is still needed. 

VA OIG Office of Healthcare Inspections 13 
CAP Review of the Coatesville VA Medical Center, Coatesville, PA 

	 Every ongoing professional practice evaluation will contain the provider names 

and review period dates. 

	 The Position Standard Board’s use of ongoing professional practice evaluation 

information will be sufficiently documented in each set of minutes in which a 

re-privileging action is described. 

 All handwritten amendments/corrections to privileging applications will be dated 

and initialed. 

 Privileges that depend on a soon-to-be-completed certification will not be 

included in the privilege request until the certification is achieved. 

Recommendation 4. We recommended that normal test results be consistently 

communicated to patients within the specified timeframe. 

Concur 

Target date for completion: Completed 

Action Plan: Providers were reeducated on the process to inform patients of normal 

test results. Process developed to consistently monitor communication of test results to 

patients. Monitoring was implemented December 1, 2010. This data is reported in the 

Primary Care Quarterly report. This report is reviewed by the Primary Care Executive 

Council and the Administrative/Clinical Operations Management Board. A random 

review of December and January notifications revealed 100 percent compliance. 

Recommendation 5. We recommended that employees receive annual MDRO training 

that includes the color-coded isolation precautions and that the training be consistently 

documented. 

Concur 

Target date for completion: March 31, 2011 

Action Plan: Developed a Learning Management System training log to record 

trainings on January 3, 2011. Revise annual infection control training to include 

MDRO/infection prevention precaution guideline. Create a Learning Management 

System module on infection prevention precaution guidelines to provide hospital wide 

training now, annually, and in new employee orientation. 

VA OIG Office of Healthcare Inspections 14 
CAP Review of the Coatesville VA Medical Center, Coatesville, PA 

Appendix F 

OIG Contact and Staff Acknowledgments 

Contact Judith Thomas, RN, Team Leader 

Baltimore Office of Healthcare Inspections 

Contributors Jennifer Christensen, DPM 

Myra Conway, RN 

Melanie Cool, RD 

Kimberly Pugh, RN 

Clarissa Reynolds, MBA 

Sonia Whig, RD 

Mark Lazarowitz, Newark Office of Investigations 

VA OIG Office of Healthcare Inspections 15 
CAP Review of the Coatesville VA Medical Center, Coatesville, PA 

Appendix G 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VA Healthcare (10N4) 

Director, Coatesville VA Medical Center (542/00) 

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: Robert P. Casey, Jr.; Patrick J. Toomey 

U.S. House of Representatives: Jim Gerlach, Pat Meehan, Joseph R. Pitts, Todd Platts 

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

VA OIG Office of Healthcare Inspections 16