Administrative Investigations: Do it


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Administrative Investigations:

Do it



First Time

Resource Guidebook

Department of Veterans Affairs

Employee Education System July 2004


Please be advised that this administrative investigation guidebook is intended only as a training tool and guide. It is sincerely hoped that its contents will serve to facilitate the three (3) stages of the investigative process: Planning and preparation, fact gathering, and analysis and report writing. It should not be viewed as a formal policy nor should it be interpreted as such. Further, its contents do not necessarily apply to investigations conducted by the Office of Inspector General.


In investigation is a methodical process whereby the true facts about a situation or event are ascertained. An individual assigned to act as a member on a board of investigation normally has minimal investigative experience. This training handbook is intended to act as a guide to the investigative process. It will familiarize the board member with the components of the process and educate the board member in the skills necessary to achieve the board’s goals.

The Guidebook was originally developed and prepared by:

Ron Angel

Director, VA Law Enforcement TC

2200 Fort Roots Drive 07A/NLR

North Little Rock, AR 72114

Nancy M. Moran

Office of Regional Counsel

4800 Memorial Drive

Waco, TX 76711

Bill Robbins

Director, VBA-HRM Center

1600 East Woodrow Wilson Avenue

Jackson, MS 39216

Steven Wise

Investigator, VA IG

801 I Street, NW

Washington, DC 20001

Terry Wolk

Office of Regional Counsel

1240 E. 9th Street

Cleveland, OH 44199

This guidebook was revised in 2004 through the efforts of the following individuals in collaboration with the Employee Education System:

Larry Ables

Senior Employee Relations Specialist

Office of Human Resources Management

Washington, DC 20420

Catherine J. Baranek

Employee Relations Specialist

Office of Human Resources Management

Washington, DC 20420

George Corsoro

Management Analyst

National Cemetery Administration

Washington, DC 20420

Meghan Serwin Flanz

General Attorney

Office of General Counsel

Washington, DC 20420

Dan Kowalski

HRM Consultant

Veterans Health Administration

Washington, DC 20420

Mauricio Ponce

Human Resources Officer

VA Medical Center

6439 Garners Ferry Road

Columbia, SC 29209
Clara Trapnell

HRM Consultant

Veterans Health Administration

Washington, DC 20420

1. Administrative InvestigationS 4

1.1 Definitions 4

1.2 Authority 4

1.3 Purpose 4

1.4 Mandatory Investigations 4

1.5 Discretionary Investigations 5

1.6 Focused Reviews 5

1.7 Peer Reviews 6

1.8 Supervisory Fact Finding 6

1.9 Potential Applications of an Administrative Investigation 6

2. The Investigation Process 7

2.1 Initiation of the Investigation (the basics) 7

Authorization Letter 7

Panel Appointment 7

Administration of Oaths 7

Recording the Proceedings 7

Timeliness of Reporting Requirements 7

Qualified Immunity from Defamation Lawsuits 8

2.2 The Planning Stage – Laying the Groundwork 8

Framework and Goal 8

Essential Components 8

2.3 Employee Rights, Obligations, and Other legal Issues 11

Employee Cooperation 11

Self-Incrimination 11

Retaliatory Actions 12

Right to Representation 12

Union Representation 13

Release of Information 14

Release of Individual Testimony 14

Degree of Proof Required 15

Referral of Issue involving alleged criminal activity to OIG 15

2.4 Evidence 16

Classification of Evidence 16

Types of Evidence 16

Relevancy, Competency, and Hearsay 16

2.5 Collection of Evidence 18

Witness Interview Process 21

Recording and Transcribing 22

The Interview Environment 22

Witness Order 22

Interviewer Skills 23

Influencing Factors 23

Interview Techniques 26

Strategies 27

Types of Questions 28

Witness Credibility 28

3. Analysis 37

3.1 Introduction 37

3.2 Identify Central Issues and Sub-issues 37

Identify Relevant Standards and Elements 37

Relevance, Quality, and Quantity 38

Credibility of Testimony 39

3.3 When to Terminate the Investigation 40

4. Preparing the Report of Investigation 42

    1. Definition: An administrative investigation is an impartial inquiry, authorized by a facility director or higher level manager, to be conducted at any time deemed necessary, to determine facts and collect evidence in connection with a matter in which the VA is or may be a part in interest.

    2. Authority: The Secretary of Veterans Affairs is responsible for assuring compliance with the laws governing veterans benefits. To assure that the intent of these laws is fulfilled, alleged irregularities in the administration of these laws, and violations of regulations and policies of the department, must be investigated. Though investigations may be ordered in any branch of the VA, provisions of the Department of Veterans Affairs Directive and Handbook 0700 (dated March 25, 2002) addresses when and in what circumstances formal boards of investigation may be required. A facility Director may also authorize an administrative investigation in cases other than those incidents stipulated by agency policy and guidelines.

    3. Purpose of the Investigation: The purpose of an investigation is to compile factual information upon which to base conclusions, recommendations, actions, or decisions, where no action is supported. Investigations also identify areas for improvement and/or identify system problems, and can preserve and record recollections for future use. Administrative investigations are not appropriate forums for pursuing allegations of criminal conduct, which must be referred to the proper authority in accordance with VA Manual MP-1, Part I, Chapter 16.

    4. Mandatory Investigations: Certain incidents require mandatory investigations in the VHA, and may prompt investigation in other branches of the VA. Where there are indications of criminal activity, the incidents should be referred to criminal investigators, before a decision is made to initiate an administrative investigation. Mandatory investigations include:

Alleged patient abuse: Acts against patients that involved physical, psychological, sexual, or verbal abuse. VA directives state that the "intent" of an employee to abuse is not a determinant as to whether an incident meets the categorization requirements for patient abuse. However, to sustain charges through arbitration or Merit Systems Protection Board (MSPB) hearings, intent often becomes an essential element. The patient's perception of how he was treated is an essential component of this determination; the fact that a given patient has limited or no cognitive ability does not exclude the possibility that abuse occurred.
Deaths: Deaths related to procedure, equipment malfunctions, or failure to diagnose;
Falls: Resulting in patient death;
Homicide: The death of a patient or staff member intentionally caused by a patient, or the death of a patient intentionally caused by another individual;
Medication errors: resulting in serious injury or death;
Missing Patients: found seriously injured or dead;
Patient or staff assaults: resulting in serious injury or death;
Patient injury (including medical device-related injury): resulting in serious injury or death;
Sexual Assault;
Transfusion errors: Blood administered to the wrong patient; administered when not ordered; etc. that results in serious injury or death;
Sentinel errors: A sentinel event is an adverse event that results in the loss of life or limb or permanent loss of function. Examples of sentinel events: death resulting from medication error, an assault, or suicides by patients who received services from the medical facility within the prior 30 days;

Adverse events: Deemed likely to trigger substantial negative publicity;

Unplanned clinical occurrences: Unplanned clinical occurrences are occurrences that result in hospitalization or increased hospital stay for more than observation (including, but not limited to, injuries resulting from assaults against patients or staff, sexual assaults, suicide attempts, patient abuse, fires, falls, and medication errors); identified error that could have, but by chance did not, result in a sentinel event or an adverse event involving hospitalization or increased hospital stay for more than observation; unplanned clinical occurrences which may result from either acts of commission or omission, e.g., administration of the wrong medication or failure to make a timely diagnosis of cancer;
Potentially compensable events: Such as determined by the Chief of Staff.

    1. Discretionary Investigations or Focused Program Reviews may be conducted when there is a(n):

Allegation or complaint regarding an organization having involvement with the VA;
Loss, theft, or destruction of government or personal property or funds, once declined for criminal investigation;
Incident or circumstance, that effects or impact upon the efficiency, reputation, or image of the Department, which the Director believes should be investigated.

    1. Focused Reviews: The VHA Patient Safety Improvement Handbook (PSI) lists adverse events, which must be reported to the Veterans Integrated Service Network (VISN). A focused review will be conducted for each event. Adverse events are untoward incidents, therapeutic misadventures, iatrogenic injuries or unexpected occurrences that have negative consequences. Sentinel events and unplanned clinical occurrences are the major categories of adverse events. A sentinel event is an adverse event that results in the loss of life or limb or permanent loss of function. Examples of sentinel events: death resulting from medication error, an assault, or suicides by patients who received services from the medical facility within the prior 30 days, and adverse events deemed likely to trigger substantial negative publicity.

    2. Peer Reviews: Peer reviews provide a practitioner with a timely opinion of a peer concerning:

The quality and appropriateness of medical care provided a patient when a medical center fails to meet pre-established quality assurance criteria, as the result of an unexpectedly adverse patient outcome; or
The Filing of an action in a court of competent jurisdiction against the Department of Veterans Affairs and/or a medical center as the result of an incidence of alleged medical malpractice (tort claim), or
As requested by competent authority.

    1. Supervisory Fact Finding: Supervisory fact finding is used for initial gathering of facts associated with a particular incident, usually by collecting individual signed statements. These statements are not sworn. This process may indicate an administrative investigation may become necessary to resolve conflicting statements that will be relied on by the department for further action.

    2. Potential Applications of an Administrative Investigation Work Product:

Tort Claims: Investigations that look into individual events may be used in investigations of tort claims filed against the agency.

Equal Employment Opportunity (EEO): May be used as evidence in litigation against the agency.

Disciplinary Boards: Administrative investigations may serve as evidence in support of major adverse actions taken against employees.

Merit Systems Protection Board (MSPB): May serve as evidence in support of adverse actions taken against employees

Workers Compensation: May be used as evidence for or against a lost time injury claim against the agency.

Disciplinary Actions: May serve as evidence in support of admonishments, reprimands, suspensions, or discharges.

State Licensing Boards: May serve as basis for reporting substandard patient care to an individuals licensing board.

Clinical Privileges: May serve as the basis for reduction or revocation of clinical privileges.
Criminal Proceedings
Reduction and/or Revocation of Privileges

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