106VA17
Compliance Records, Response, and Resolution of Reports of Persons Allegedly Involved in Compliance Violations-VA
System location:
All computerized and paper records are located at: Department of
Veterans Affairs (VA) Headquarters, 810 Vermont Avenue, NW,
Washington, DC 20420; Veterans Integrated Services Networks (VISN);
and, VA health care facilities. Address locations for VA facilities
are listed in VA Appendix 1 of the biennial publication of the
Privacy Act Issuances.
Categories of individuals covered by the system:
The following categories of individuals will be covered by the
system: (1) Employees, (2) veterans, (3) third parties such as
contractors who conduct official business with the Veterans Health
Administration (VHA), and (4) subjects of complaints and
complainants. Complainants are individuals who have reported a
possible violation of law, rules, policies, regulations, or external
program requirements, such as third-party payor billing guidelines.
Categories of records in the system:
Records (or information contained in records) in this system
include allegations made by individuals calling VHA's Compliance
Line, or through another source, to report a possible violation of
law, rules, policies, regulations, or external program requirements
such as third-party payor billing guidelines. Records also may
contain reports of the reviews or investigations conducted at the
medical center, VISN, or Headquarters level to verify the reported
allegations and take remedial action as needed. The VHA Compliance
Office will maintain a copy of these reports. Information in this
system regarding reports of suspected non-compliance may include: (1)
The name, home and work address and phone number of the complainant;
(2) the name of the subject of the complaint; (3) the name and/or
patient number of veteran patient who received services associated
with the complaint; (4) the date when the allegation was reported;
(5) the date, location and nature of the alleged wrongdoing; and (6)
the Compliance Office's identification number assigned to the case.
The records may also include correspondence between the Compliance
Office and the Compliance Line contractor as to the status of each
case (open or closed).
Information in the investigation records may include: (1) The
name of the subject of an investigation; (2) the names of individuals
whose work was reviewed as part of the investigation; (3) the names
and/or patient numbers of veteran patients whose medical records were
reviewed in order to investigate the allegation; (4) the station at
which an investigation took place; (5) the time period when the
investigation took place; (6) the nature of the allegation; (7) the
outcome of the investigation; (8) the recommended action; and, (9)
the Compliance Office's identification number assigned to the case.
Information may be in the form of a narrative summary or synopsis,
exhibits, or internal documentation and memoranda.
Records in the system will be a combination of computerized files
and paper files. Both paper and electronic records may contain the
information listed above, and may relate to complainants and subjects
of complaints.
Authority for maintenance of the system:
Title 38 United States Code, section 501.
Purpose(s):
The purpose is to establish a process to receive reports of
suspected compliance violations, and to maintain a system to respond
to such allegations.
Routine uses of records maintained in the system, including
categories of users and the purposes of such uses:
- The record of an individual who is covered by this system may
be disclosed to a Member of Congress or staff person acting for the
member when the member or staff person requests the records on behalf
of and at the request of that individual.
- Any information in this system may be disclosed to a Federal
agency, upon its official request, to the extent that it is relevant
and necessary to that agency's decision regarding: the hiring,
retention or transfer of an employee, the issuance of a security
clearance, the letting of a contract, or the issuance or continuance
of a license, grant or other benefit given by that agency. However,
in accordance with an agreement with the U.S. Postal Service,
disclosures to the U.S. Postal Service for decisions concerning the
employment of veterans will only be made with the veteran's prior
written consent.
- Any information in this system may be disclosed to a State or
local agency, upon its official request, to the extent that it is
relevant and necessary to that agency's decision on: The hiring,
transfer or retention of an employee, the issuance of a security
clearance, the letting of a contract, or the issuance or continuance
of a license, grant or other benefit by the agency; provided, that if
the information pertains to a veteran, the name and address of the
veteran will not be disclosed unless the name and address is provided
first by the requesting State or local agency.
- Any information in this system, except the name and address of
a veteran, may be disclosed to a Federal, State or local agency
maintaining civil or criminal violation records, or other pertinent
information such as prior employment history, prior Federal
employment background investigations, and/or personal or educational
background in order for VA to obtain information relevant to the
hiring, transfer or retention of an employee, the letting of a
contract, the granting of a security clearance, or the issuance of a
grant or other benefit. The name and address of a veteran may be
disclosed to a Federal agency under this routine use if this
information has been requested by the Federal agency in order to
respond to the VA inquiry.
- Any information in this system, except the name and address of
a veteran, which is relevant to a suspected violation or reasonably
imminent violation of law, whether civil, criminal or regulatory in
nature and whether arising by general or program statute or by
regulation, rule or order issued pursuant thereto, may be disclosed
to a Federal, State, local or foreign agency charged with the
responsibility of investigating or prosecuting such violation, or
charged with enforcing or implementing the statute, regulation, rule
or order issued pursuant thereto.
- The name and address of a veteran, which is relevant to a
suspected violation or reasonably imminent violation of law, whether
civil, criminal or regulatory in nature and whether arising by
general or program statute or by regulation, rule or order issued
pursuant thereto, may be disclosed to a Federal agency charged with
the responsibility of investigating or prosecuting such violation, or
charged with enforcing or implementing the statute, regulation, rule
or order issued pursuant thereto, in response to its official
request.
- The name and address of a veteran, which is relevant to a
suspected violation or reasonably imminent violation of law
concerning public health or safety, whether civil, criminal or
regulatory in nature and whether arising by general or program
statute or by regulation, rule or order issued pursuant thereto, may
be disclosed to any foreign, State or local governmental agency or
instrumentality charged under applicable law with the protection of
the public health or safety if a qualified representative of such
organization, agency or instrumentality has made a written request
that such name and address be provided for a purpose authorized by
law.
- Any information in this system may be disclosed to the U.S.
Office of Special Counsel, upon its official request, when required
for the Special Counsel's review of the complainant's allegations of
prohibited personnel practices.
- The name, address, and other identifying data, including
title, date and place of birth, social security number, and summary
information concerning an individual who, for fraudulent or deceitful
conduct either as an employee or while conducting or seeking to
conduct business with the Agency, has been convicted of violating
Federal or State law or has been debarred or suspended from doing
business with VA, may be furnished to other Federal agencies to
assist such agencies in preventing and detecting possible fraud or
abuse by such individual in their operations and programs. This
routine use applies to all information in this system of records
which can be retrieved by name or by some identifier assigned to an
individual, regardless of whether the information concerns the
individual in a personal or in an entrepreneurial capacity.
- Records from this system of records may be disclosed to a
Federal agency or to a State or local government licensing board and/
or to the Federation of State Medical Boards or a similar non-
government entity which maintains records concerning individuals'
employment histories or concerning the issuance, retention or
revocation of licenses, certifications, or registration necessary to
practice an occupation, profession or specialty, in order for the
agency to obtain information relevant to an agency decision
concerning the hiring, retention or termination of an employee or to
inform a Federal agency or licensing boards or the appropriate non-
government entities about the health care practices of a terminated,
resigned or retired health care employee whose professional health
care activity so significantly failed to conform to generally
accepted standards of professional medical practice as to raise
reasonable concern for the health and safety of patients in the
private sector or from another Federal agency. These records may also
be disclosed as part of an ongoing computer matching program to
accomplish these purposes.
- Relevant information from this system of records related to
final adverse actions taken against a health care provider, supplier,
or practitioner may be disclosed to the Health Integrity and
Protection Data Bank (HIPDB) (45 CFR part 61). The information to be
reported includes: (1) The name and Taxpayer Identification Number
(as defined in section 7701 (a)(41) of the Internal Revenue Code of
1986) of any health care provider, supplier, or practitioner who is
the subject of a final adverse action; (2) the name of any health
care entity, if known, with which a health care provider, supplier,
or practitioner, who is the subject of a final adverse action, is
affiliated or associated; (3) the nature of the final adverse action
and whether such action is on appeal; and (4) a description of the
acts or omissions and injuries upon which the final adverse action
was based, and such other information as the Secretary, Department of
Health and Human Services, determines by regulation is required for
appropriate interpretation of information reported. Information
reported will be considered confidential and shall not be disclosed
except as specified in the HIPDB regulations.
- Disclosure of relevant information may be made to
individuals, organizations, private or public agencies, etc., with
whom VA has a contract or agreement to perform such services as VA
may deem practicable for the purposes of laws administered by VA, in
order for the contractor or subcontractor to perform the services of
the contract or agreement.
- For program review purposes and the seeking of accreditation
and/or certification, disclosure may be made to survey teams of the
Joint Commission on Accreditation of Healthcare Organizations
(JCAHO), College of American Pathologists, American Association of
Blood Banks, and similar national accreditation agencies or boards
with which VA has a contract or agreement to conduct such reviews but
only to the extent that the information is necessary and relevant to
the review.
- Disclosure may be made to the National Archives and Records
Administration (NARA) in records management inspections conducted
under authority of Title 44 United States Code.
Policies and practices for storing, retrieving, accessing,
retaining, and disposing of records in the system:
Storage:
All reports of suspected noncompliance will be documented in a
computerized database and assigned a unique identification number.
Paper files may also be maintained which contain documents collected
in association with reviewing the case, such as memoranda, policies,
or examples of work produced as a result of the complaint.
Retrievability:
Both electronic and paper case files will be stored and
individually retrieved by the unique identification number, not by
name.
Safeguards:
Access to computerized information in the database is restricted
to authorized personnel on a need-to-know basis by means of passwords
and authorized user identification codes. Computer system
documentation will be maintained in a secure environment in the VHA
Office of the Chief Financial Officer (CFO) Compliance Office, and in
the Compliance Offices at the network and medical center locations.
Physical access to printouts and data terminals will be limited to
authorized personnel in the Compliance Program.
Access to file folders is restricted to authorized personnel on a
need-to-know basis. Paper files are maintained in file cabinets or
closets and are locked after duty hours. These files are under the
control of the Compliance Officer or his/her designees. Buildings are
protected from unauthorized access by a protective service.
Retention and disposal:
Computerized records will be retained indefinitely. Periodic
system back-ups will be employed for record protection. If disk space
is limited, the records will be archived to tape or disk in
accordance with established practice. Paper records will be
maintained and disposed of in accordance with records disposition
authority approved by the Archivist of the United States.
System manager(s) and address:
VHA Chief Financial Officer (17), Department of Veterans Affairs,
810 Vermont Avenue, NW., Washington, DC 20420.
Notification procedure:
An individual who wishes to know if a record is being maintained
by the VHA CFO Compliance Office under his or her name in this system
or wants to determine the contents of such records should submit a
written request or apply in person to the VHA CFO (17).
Record access procedures:
An individual who seeks access to or wishes to contest records
maintained under his or her name in this system may write, call or
visit the VHA CFO (17).
Contesting record procedures:
(See Record Access Procedures above.)
Record source categories:
The information in this system will be obtained from calls that
are received on the Compliance Line and reports received through
other sources. Information is obtained from VHA employees, veterans,
third parties such as contractors, and VHA records which may include
billing data, patient medical records, policies and procedures, and
memoranda.
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