Veteran Oversight Now

In the latest episode of Veteran Oversight Now, a VA OIG healthcare inspection hotline director discusses a telemetry technician’s failure to follow a series of communications within the time frame established in the facility’s cardiac telemetry monitoring policy delayed initiating a code blue alert, ending with the patient’s death. This edition also includes highlights of the VA OIG’s work from March 2024.       “Once the patient's heart rate completely stopped and they went into asystole, that should have triggered a code blue. Period.” – Trina Rollins, VA Office of Inspector General, Office of Healthcare Inspections, Hotline Director Related Report: Care Deficiencies and Leaders’ Inadequate Reviews of a Patient Who Died at the Lt. Col. Luke Weathers, Jr. VA Medical Center in Memphis, Tennessee

In the latest episode of Veteran Oversight Now, a VA OIG healthcare inspection hotline director discusses how multiple OIG reports detail chronic leadership failures at the Indianapolis, Indiana VA medical center. This edition also includes highlights of the VA OIG’s work from February 2024.       “It overall affects the care that the patients receive. Some of the care just wasn’t available anymore because they didn’t have the cardiologists available.” – Trina Rollins, VA Office of Inspector General, Office of Healthcare Inspections, Hotline Director

In the latest episode of Veteran Oversight Now, a VA OIG healthcare inspection hotline director discusses delays in the receipt of patients’ colorectal cancer screening tests due to an unpaid postage bill by the Phoenix VA Health Care System in Arizona. This edition also includes highlights of the VA OIG’s work from January 2024.       “The VISN actually led a stand-down at the facility to retrain all of the laboratory staff about the test, about the assessing of the test and processing it. And then they also passed all of that information to all of the other facilities within VISN 22. So, it wasn’t just Phoenix, you know, they made sure all of the facilities in VISN 22 had the same information and the same knowledge. So, to follow that up, they’re doing weekly audits and checking to make sure that the logging process is being done correctly. And so far, the reported compliance has been 100 percent.” – Trina Rollins, VA Office of Inspector General, Office of Healthcare Inspections, Hotline Director Related Report: Delayed Receipt of Patients’ Colorectal Cancer Screening Tests at the Phoenix VA Health Care System in Arizona

In the latest episode of Veteran Oversight Now, VA Inspector General Michael J. Missal shares his thoughts on changes to federal oversight since the passage of the Inspector General Act in 1978, which established 12 presidentially appointed IGs in federal departments with a mission to provide independent oversight. The VA OIG was one of the original 12. He also discusses the VA OIG’s latest Semiannual Report to Congress that covered oversight work from April 1 to September 30, 2023. This edition also includes highlights of the VA OIG’s work from October 2023.       “As only the sixth Senate-confirmed VA Inspector General over the past 45 years, it is truly an honor and privilege to work on behalf of veterans and taxpayers. It is also a real honor and privilege to work with all of our staff to meet our mission of meaningful independent oversight. We had a great fiscal year 2023 and we look forward to an even more impactful fiscal year 2024.” – VA Inspector General Michael J. Missal Related Reports: VA’s Compliance with the VA Transparency & Trust Act of 2021 Semiannual Report: September 2023Manufacturers Failed to Make Some Drugs Available to Government Agencies at a Discount as RequiredReview of Access to Telehealth and Provider Experience in VHA Prior to and During the COVID-19 PandemicRead the VA OIG's 90th Semiannual Report to Congress.

In this latest episode of Veteran Oversight Now, a VA OIG healthcare inspection hotline director discusses the lessons learned in the care of a veteran who died after a fall in a VA outpatient clinic, part of the Southern Nevada Healthcare System in Las Vegas. This edition also includes highlights of the VA OIG’s work from August 2023.       “Since [the incident] happened, the facility has made several adjustments to ensure that in an emergency situation that staff is knowledgeable of the processes that they need to implement and carry out that will hopefully result in a better outcome.” – Trina Rollins, VA Office of Inspector General, Office of Healthcare Inspections, Hotline DirectorRelated Report: Quality of Care Concerns and the Facility Response Following a Medical Emergency at the VA Southern Nevada Health Care System in Las VegasPublished: 6/28/2023Report #22-02725-132

In the latest episode of Veteran Oversight Now, a VA OIG healthcare inspection hotline director discusses deficiencies in the quality of emergency department care for a veteran who died by suicide at the John Cochran Division of the VA St. Louis Healthcare System in Missouri. This edition also includes highlights of the VA OIG’s work from July 2023.“Approximately 10 minutes later is when the staff person finds the patient unresponsive in the exam room with a ligature around his neck. A code was called, meaning a code blue so that all emergency staff would present to that room, and they tried to resuscitate the patient, but that was unsuccessful, and he was pronounced dead about 10 to 15 minutes later.” – Trina Rollins, VA Office of Inspector General, Office of Healthcare Inspections, Hotline Director Related ReportDeficiencies in Emergency Department Care for a Patient Who Died by Suicide at the John Cochran Division of the VA St. Louis Health Care System in Missouri

In the latest episode of Veteran Oversight Now, a VA OIG healthcare inspection hotline director discusses missteps in the care of a veteran who eventually committed suicide on the grounds of the Aiken Community Based Outpatient Clinic, part of the Charlie Norwood VA Medical Center in Augusta, Georgia. This edition also includes highlights of the VA OIG’s work from June 2023.       “In VA you're assigned a primary care provider called your PCP, that, in theory, should be the main provider you see. That's where all of your referrals start for specialty care, and that's how you gain continuity of care. Unfortunately, with this veteran he saw one provider, and then the next appointment saw a different provider, and then the third appointment saw a third provider.” – Trina Rollins, VA Office of Inspector General, Office of Healthcare Inspections, Hotline Director  Related Report:Deficient Care of a Patient Who Died by Suicide and Facility Leaders’ Response at the Charlie Norwood VA Medical Center in Augusta, Georgia

In the latest episode of Veteran Oversight Now, a VA OIG healthcare inspection hotline director discusses how she and her team triage healthcare-related hotline inquiries. She shares how concerns over the management of a patient safety program led to an inspection and subsequent report at the Tuscaloosa VA Medical Center in Alabama. This edition also includes highlights of the VA OIG’s work from May 2023.       “I think the takeaway for all of this is VHA needs to ensure involvement of all staff in the patient safety program at the respective facilities, but also ensure oversight of those safety patient safety programs. The oversight is just as important as participation when trying to ensure that the facility has opportunities to identify system vulnerabilities and then address those concerns with the hopes of preventing future patient safety events from occurring.” Trina Rollins, Director of Hotline Coordination, Office of Healthcare InspectionsRelated Publications: Deficiencies in the Patient Safety Program and Oversight Provided by Facility and VISN Leaders at the Tuscaloosa VA Medical Center in Alabama Comprehensive Healthcare Inspection of the Tuscaloosa VA Medical Center in Alabama (September 2, 2020) Comprehensive Healthcare Inspection of the Tuscaloosa VA Medical Center, Alabama (September 27, 2019)

IG Michael J. Missal discusses the VA OIG's 89th Semiannual Report to Congress covering the reporting period of October 1, 2022, to March 31, 2023. Plus oversight highlights from the VA OIG's work in March and April of 2023. For this six-month period, the VA OIG identified more than $401 million in monetary impact for a return on investment of $4 for every dollar spent on oversight. These figures do not include the inestimable value of the healthcare oversight work completed to advance patient safety and quality care. During this six-month period, the Office of Investigations opened 222 cases and closed 217 (most of which were opened in prior periods), with efforts leading to 122 arrests. The OIG hotline received and triaged 15,526 contacts to help identify wrongdoing and address concerns with VA activities. Collectively, the work during this period resulted in 595 administrative sanctions and actions. The Office of Audits and Evaluations (OAE) produced 52 work products, including one VA management advisory memorandum that highlighted concerns requiring VA’s prompt attention, 19 oversight reports, and 32 preaward and postaward contract reviews to help VA obtain fair and reasonable pricing on products and services. OAE reports for the six-month period resulted in 128 recommendations. The Office of Special Reviews issued two publications, including an administrative investigation that focused on VHA employing four people who had been previously excluded from holding a paid position in a federal healthcare program. The Office of Healthcare Inspections (OHI) focused on leadership and organizational risks, suicide risk reduction, and care coordination. OHI published 14 healthcare inspection reports; two national healthcare reviews; 11 Comprehensive Healthcare Inspection Program (CHIP) reports, including four CHIP summary reports; two Vet Center Inspection Program reports; and two Care in the Community reports.   Featured Publications:Stronger Controls Help Ensure People Barred from Paid Federal Healthcare Jobs Do Not Work for VHAVeterans Are Still Being Required to Attend Unwarranted Medical Reexaminations for Disability BenefitsDeficiencies in Lethal Means Safety Training, Firearms Access Assessment, and Safety Planning for Patients with Suicidal Behaviors by FirearmsOpioid Safety at the VA Northern California Health Care System in Mather 

In this episode, host Fred Baker talks with Dr. Julie Kroviak, the principal deputy assistant inspector general of the VA OIG’s Office of Healthcare Inspections, about changes to how cyclical healthcare reviews are conducted. Dr. Kroviak explains how her teams are reworking the Comprehensive Healthcare Inspection Program cyclical reports to provide more information on the veteran communities being served by VA medical facilities. Additionally, she shares how, for the first time, the VA OIG will start reviewing VA mental health programs cyclically.             “We're going to start with a glimpse of the community that the facility operates in, and that's totally new. We've never done anything like that but giving the reader a sense of who's living in this community, what's the education level, what's the income level, the disease burden, active duty and veteran populations, all of these [factors] sort of really influence how care is delivered, and we want to present that in a reader-friendly kind of glimpse so you can understand what's influencing care and the veterans served in that community.” – Dr. Julie Kroviak

In this episode of Veteran Oversight Now, host Fred Baker talks with Shawn Steele, the director of the VA OIG’s Office of Audits and Evaluations Healthcare Infrastructure Division. Taking a very unique approach, 150 OIG staff recently mobilized to evaluate the security posture of 70 VA medical facilities over three days. Persistent police staffing shortages and growing concerns about incidents that put VA staff, patients, and visitors at risk led the OIG to conduct the review, Security and Incident Preparedness at VA Medical Facilities. OIG teams assessed whether each VA medical facility visited had established a minimum-security posture and had taken required actions according to VA policy. The OIG identified multiple security vulnerabilities and deficiencies, most notably staffing shortages that contributed to the lack of a visible and active police presence.  “VA medical facilities are meant to be welcoming. They’re meant to be easy to access and as a result have many entrances. On top of that, there are 171 geographically diverse medical facilities in the VA network, and each of them come with their own unique challenges. It’s important to understand that there is not one [security] template that can be applied. There are 171 templates that need to be applied.” – Shawn Steele Related Report:Security and Incident Preparedness at VA Medical Facilities

In this episode of Veteran Oversight Now, host Fred Baker chats with Dr. Beth Winter, a psychiatrist with the VA OIG’s Office of Healthcare Inspections. They discuss her path from wanting to provide care for exotic animals to choosing to be “a people doctor instead of an animal doctor.” Dr. Winter’s distinguished career eventually led the granddaughter and daughter of veterans to the VA OIG helping provide oversight of VHA’s health care system. In this podcast, Dr. Winter discusses her work related to the prevention of veteran suicide by lethal means in the recently released report Deficiencies in Lethal Means Safety Training, Firearms Access Assessment, and Safety Planning for Patients with Suicidal Behaviors by Firearms. She explains that the time between a veteran deciding to act and actually attempting suicide can be just five or 10 minutes and relatively simple interventions during that period can be critical in preventing suicide. This month’s episode concludes with a summary of the VA OIG’s oversight highlights for December 2022. “That window is really between the decision to act and the action itself and … we also know that if there was some barrier to accessing a person’s initial method for suicide—for example a gun lock, or a gun being placed in a safe, or a gun being separated from ammunition within the house—that gives people time to either reconsider their action, or they might make the attempt with a method that’s significantly less lethal. So, if we can increase that window between the decision to act and the action itself, we significantly increase the possibility of that person’s survival.” – Dr. Beth Winter Related Report:Deficiencies in Lethal Means Safety Training, Firearms Access Assessment, and Safety Planning for Patients with Suicidal Behaviors by Firearms

The Semiannual Report to Congress summarizes the VA Office of Inspector General’s (OIG) oversight efforts from April 1 through September 30, 2022. For this six-month period, the VA OIG identified more than $1.4 billion in monetary impact for a return on investment of $16 for every dollar spent on oversight—which brings the fiscal year 2022 totals to nearly $4.6 billion in monetary impact for a return on investment of $24 for every dollar spent on oversight. These figures do not include the inestimable value of the healthcare oversight work completed to advance patient safety and quality care. During this six-month period, the Office of Investigations opened 178 cases and closed 213 (most of which were opened in prior periods), with efforts leading to 135 arrests. The OIG hotline received and triaged 18,396 contacts to help identify wrongdoing and address concerns with VA activities. Collectively, the work during this period resulted in 599 administrative sanctions and actions. The Office of Audits and Evaluations (OAE) produced 44 publications, including five VA management advisory memorandums that highlighted concerns requiring VA’s prompt attention. Contracting review teams also conducted 47 preaward and postaward contract reviews to help VA obtain fair and reasonable pricing on products and services. OAE reports for the six-month period resulted in 198 recommendations. The Office of Special Reviews (OSR) issued five publications, including three reports in response to allegations of senior VA officials’ misconduct, which reflect the VA OIG’s commitment to holding VA employees accountable for wrongdoing and promoting the highest standards of professional and ethical conduct. OSR also issued two joint publications: a VA management advisory memorandum with OAE regarding concerns with the calculation of patient wait time data, and a report with the Department of Defense (DoD) OIG, focusing on efforts by DoD and VA to achieve electronic health record system interoperability. The Office of Healthcare Inspections (OHI) maintained a strong focus on leadership and organizational risks, suicide risk reduction, quality of care, and patient safety. OHI published 19 healthcare inspection reports; 17 Comprehensive Healthcare Inspection Program (CHIP) reports, including three CHIP summary reports; four national healthcare reviews; and its first Care in the Community report that examined key clinical and administrative processes associated with providing quality VA and community care.  

Mentioned Investigations: Former VA Hospital Nursing Assistant Sentenced to Seven Consecutive Life Sentences for Murdering Seven Veterans and Assault with Intent to Commit Murder of an Eighth Fayetteville Doctor Sentenced To 20 Years In Federal Prison For Mail Fraud And Involuntary Manslaughter Retail Ready Owner to Forfeit $72M for VA Tuition Fraud

Related Reports:OIG Determination of Veterans Health Administration’s Occupational Staffing Shortages Fiscal Year 2022 Pursuant to the VA Choice and Quality Employment Act of 2017 (VCQEA), the OIG conducted a review to identify clinical and non-clinical occupations experiencing staffing shortages within Veterans Health Administration (VHA). This is the ninth iteration of the staffing report, and the fifth evaluating facility-level data. The OIG evaluated staffing shortages by surveying VHA facilities, and compared this information to the previous four years.The OIG found that all 139 VHA facilities reported at least one severe occupational staffing shortage. The total number of reported severe shortages was 2,622. Twenty-two occupations were identified as a severe occupational staffing shortage by at least one in five facilities. Every year since 2014, the Medical Officer and Nurse occupations were reported as severe shortages. Practical Nurse was the most frequently identified clinical severe occupational staffing shortage in FY 2022, with 62 percent of facilities reporting this occupation. Custodial Worker was the most frequently reported non-clinical severe occupational shortage in FY 2022, with 69 percent of facilities reported the occupation. Medical Support Assistance was the most frequently reported Hybrid Title 38 severe occupational shortage.In FY 2022, VHA reported twenty-two percent more severe occupational staffing shortages as compared to FY 2021. FY 2022 is the first year since implementation of VCQEA reporting requirements in which the OIG did not observe a yearly decrease in the overall number of severe occupational staffing shortages; it was also the first time that facilities identified more than 90 occupations as severe shortages. The OIG again determined the ongoing need for Custodial Worker and Medical Support Assistance, noting an increase in the number of facilities identifying these occupations as severe shortages. The OIG emphasizes the importance of VHA’s continued assessment of severe occupational staffing shortages given the increases from FY 2021 to FY 2022.The Veterans Health Administration Needs to Do More to Promote Emotional Well-Being Supports Amid the COVID-19 PandemicThe Veterans Health Administration (VHA) Office of Emergency Management issued the initial COVID-19 Response Plan on March 23, 2020, and then an updated version on August 7, 2020. The National Center for Organization Development created a COVID-19 rapid response consultation process for VHA leaders in a supervisory role. The Organizational Health Council developed a team that coordinated with multiple VHA program offices to create a COVID-19 Employee Support Toolkit and other resources. Additionally, several program offices independently created and disseminated employee well-being resources specific to the COVID-19 pandemic, including National Center for Organization Development, Patient Centered Care & Cultural Transformation, Chaplain Service, and the Office of Mental Health and Suicide Prevention.The VA Office of Inspector General (OIG) identified a generally diminishing awareness of employee emotional well-being supports in relation to organizational hierarchy, low utilization of support resources by leadership and frontline employees, as well as employee perception of inadequate support and responsiveness from leadership.The OIG conducted a review to assess how the VHA addressed the emotional well-being of employees during the COVID-19 pandemic. The OIG also conducted an overview of VHA programs, including what specialized programs were developed and deployed in response to the unique psychological challenges created by the COVID-19 pandemic for VHA’s staff. The OIG interviewed VA and VHA leaders in multiple offices. The OIG developed and deployed a survey about VHA guidance regarding employees’ emotional well-being during the pandemic, available resources, monitoring of available support programs, and employee engagement with available support programs.The OIG made one recommendation to the Under Secretary for Health related to increasing leadership and staff awareness of COVID-19 emotional well-being resources for VHA employees and awareness of resources about potential risks and signs of burnout.

Related Reports: Airborne Hazards and Open Burn Pit Registry Exam Process Needs ImprovementSince 1990, some 3.5 million veterans have served in areas that potentially exposed them to airborne hazards and open burn pit toxins, which have been associated with health problems. In 2013, Congress ordered VA to establish a registry to research the potential health impacts of exposures. The VA Office of Inspector General (OIG) reviewed the management of registry exams, including whether VA medical facilities conducted them within the 90-day prescribed period. The Veterans Health Administration (VHA) began collecting and recording data in the registry in May 2014 through an online questionnaire and free in-person exams. The OIG found many veterans did not complete the 140-item questionnaire, which is not clear and veteran-centric. Veterans also did not always realize they were responsible for scheduling their own exams. Improvements in the registry exam process would help ensure more eligible and interested veterans receive them. VHA plans to establish a call center to assume some of the scheduling and coordination responsibilities by October 2022. This is well-timed given the number of veterans indicating they would like an exam has further increased since August 2021, when VA established a presumptive “service connection” for respiratory conditions due to exposure to particulate matter, such as asthma, sinusitis, and rhinitis. Whether the call center will mitigate the issues identified by the OIG cannot yet be determined, and its rollout does not negate the need for corrective actions. The OIG made seven recommendations to the under secretary for health that include revising the questionnaire to be more veteran-centric, identifying whether veterans with unscheduled exams are still interested in one, and implementing processes and metrics to ensure exams are completed. Further, the OIG recommended developing guidance to ensure responsible parties review and discuss performance data and the enhancement of registry information systems. Veterans Prematurely Denied Compensation for Conditions That Could Be Associated with Burn Pit ExposureVA recognizes exposure to smoke from the large burn pits used by the US military to dispose of waste from its bases in Iraq, Afghanistan, and Djibouti as a potential cause of disabilities. Veterans Benefits Administration (VBA) staff processed more than 21,100 burn pit-related claims from June 2007 through September 2021. Given the potential impact on many eligible veterans, the VA Office of Inspector General (OIG) conducted this review to determine whether VBA staff followed regulations and procedures when addressing conditions that could be associated with burn pit exposure. VBA treats burn pit-related claims like most other disability compensation claims, though it also considers exposure to environmental hazards based on a veteran’s service location. VBA provides medical examiners a burn pit fact sheet to help ensure any opinion is fully informed based on all known objective facts. The review team examined three distinct samples of claimed conditions potentially related to burn pit exposure completed from May 1, 2020, to May 1, 2021, and found VBA could improve its processing and oversight. Though VBA staff nearly always made the correct decision in granting compensation for conditions identified as burn pit-related, the OIG found most denials were premature. The OIG made seven recommendations to VBA management, including correcting four errors involving improperly granted conditions, and reviewing denied cases, correcting errors they identify, and certifying that corrections were made. VBA should also update its adjudication procedures manual to provide separate and specific guidance for handling claims based on burn pit exposure and modify its examination request application to add specialty language from the burn pit fact sheet into medical opinion requests. Finally, VBA should update training materials and ensure they are consistent with the adjudication procedures manual guidance.

The Office of Investigations investigates potential crimes and civil violations of law involving VA programs and operations committed by VA employees, contractors, beneficiaries, and other individuals. These investigations focus on a wide range of matters including healthcare, procurement, benefits, construction, and other fraud; cybercrime and identity theft; bribery and embezzlement; drug offenses; and violent crimes. The office is staffed by special agents with full law enforcement authority, forensic auditors, and other professionals. Learn more at https://www.va.gov/oig/about/investigations.asp 

Related report: Contract Medical Exam Program Limitations Put Veterans at Risk for Inaccurate Claims DecisionsReport summary: Given the importance of medical exams to disability claims and the high cost of VA’s contracts with exam vendors, the VA Office of Inspector General (OIG) set out to determine whether the Veterans Benefits Administration (VBA) oversaw contract medical disability exams to ensure they met quality standards and contractual requirements, established procedures for correcting errors, and gave feedback to vendors to improve exam quality.VBA’s governance of and accountability for the exam program needs to improve. The identified deficiencies appear to have persisted, at least in part, because of limitations with VBA’s management and oversight of the program at the time of the review. The OIG found VBA’s program was deficient because it hindered the ability to hold vendors accountable for correcting errors and improving exam accuracy. VBA should improve the program to help ensure vendors produce accurate exams to support correct decisions for veterans’ claims.Contract exams are a significant investment, and VA has spent nearly $6.8 billion since fiscal year 2017. Some of the exams produced by vendors have not met contractual accuracy requirements. As a result, claims processors may have used inaccurate or insufficient medical evidence to decide veterans’ claims. Therefore, it is vital for VBA to improve the governance and accountability of the program.The OIG made four recommendations to the acting under secretary for benefits, including ensuring vendors can be held contractually accountable for unsatisfactory performance and establishing procedures for vendors to correct errors. The OIG also recommended requiring the Medical Disability Examination Office to communicate vendor exam errors to the Office of Field Operations and the regional offices and demonstrate progress in correcting them, and analyze all available data to identify systemic errors and provide systemic exam issues and error trends to vendors.

In this episode of Veteran Oversight Now, guest host Deputy Inspector General David Case joins Dr. Joe Etherage, director of national reporting for the Office of Healthcare Inspections, to discuss three recently released reports on VA’s Electronic Health Record Modernization program—a 10-year, multibillion-dollar modernization effort. Since the October 2020 implementation of the system at the Mann-Grandstaff VA Medical Center in Spokane, Washington, the VA OIG has received wide-ranging complaints to its hotline as well as concerns from members of Congress. The VA OIG found deficiencies that increased risks to patient safety.Referenced reports: Medication Management Deficiencies after the New Electronic Health Record Go-Live at the Mann-Grandstaff VA Medical Center in Spokane, WashingtonTicket Process Concerns and Underlying Factors Contributing to Deficiencies after the New Electronic Health Record Go-Live at the Mann-Grandstaff VA Medical Center in Spokane, WashingtonCare Coordination Deficiencies after the New Electronic Health Record Go-Live at the Mann-Grandstaff VA Medical Center in Spokane, Washington 

In this episode of Veteran Oversight Now, Dr. Julie Kroviak, deputy assistant inspector general for healthcare inspections, discusses her journey from medical student to VA doctor to leading teams conducting oversight of VHA. She introduces the new vet center inspection program, detailing how the VA OIG will inspect roughly 300 vet centers over the next few years. This month’s episode concludes with the VA OIG’s highlights for January 2022. Dr. Kroviak on areas of focus for vet center inspections:“Leadership will be a story that we tell in every single report we write from now on. We’re looking at leadership in local and regional levels for each vet center that we visit. Importantly, we’re looking for their internal quality reviews. You know care is being provided, and we need to know that there is appropriate oversight and intervention and when issues are found that plans are in place to remediate.”The VA OIG has published inspection reports on the following vet centers since the program was launched:Pacific District 5 Zone 1 and four selected vet centers in Bellingham, WA; Tacoma, WA; Bend, OR; and Wasilla, AK, 9/30/21Continental District 4 Zone 2 and four selected vet centers in Alexandria, LA; Houston Southwest, TX; Laredo, TX; and Mesquite, TX, 9/30/21Southeast District 2 Zone 2 and four selected vet centers in Clearwater, FL;  Ocala, FL; Sarasota, FL; and Ponce, Puerto Rico, 9/30/21Continental District 4 Zone 1 and four selected vet centers in Casper, WY; Denver, CO; El Paso, TX; and Midland, TX, 12/2/21Pacific District 5 Zone 2 and four selected vet centers in Fresno, CA; High Desert, CA; Santa Cruz County, CA; and Honolulu, HI, 12/20/21