through 17.416, and the terms and conditions of the grant award.

(d) For the purposes of the entire chapter, 38 U.S.C., Chapter 82, any unobligated funds remaining in a grant account at the close of the award period may be carried forward and will be available during a subsequent award period within the approved program period. The amount of any subsequent award will take into consideration any unobligated balance in the grant account. At the end of the last award period of the approved program period, any unobligated funds remaining must be refunded to the Federal Government.

[38 FR 26192, Sept. 19, 1973, as amended at 46 FR 33523, June 30, 1981]

§ 17.408 Nondiscrimination.

(a) Grants made under 38 U.S.C. Chapter 82 shall be subject to Title IX of the "Education Amendments Act of 1972" (effective July 1, 1972) and regulations promulgated by the Department of Education. Such title prohibits sex discrimination in all federally assisted education programs.

(b) Grants made under Pub. L. 92541 (86 Stat. 1100) shall be subject to Title VI of the Civil Rights Act of 1964 (78 Stat. 252) which provides that no person in the United States shall on the grounds of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subject to discrimination under any program or activity receiving Federal financial assistance. Regulations implementing such Title VI have been issued as §§ 18.1 through 18.4 of this chapter.

(c) Grant funds used for remodeling, alteration, or repairs shall be subject to the condition that the grantee shall comply with the requirements of Executive Order 11246, 30 FR 12319 (September 24, 1965), as amended, and with the applicable rules, regulations, and procedures pursuant thereto.

[38 FR 26192, Sept. 19, 1973, as amended at 46 FR 33523, June 30, 1981]

§ 17.409 Publications and copyright.

Except as may otherwise be provided under the terms and conditions of the award, the grantee may copyright

without prior approval any publications, films, or similar materials developed or resulting from a project supported by a grant under §§ 17.400 through 17.416, subject, however, to a royalty free, nonexclusive, and irrevocable license or right in the Government to reproduce, translate, publish, use, disseminate, and dispose of such materials and to authorize others to do so.

[38 FR 26192, Sept. 19, 1973]

§ 17.410 Accountability.

The recipient shall allocate expenditures from the grant award between direct and indirect costs according to generally accepted accounting procedures.

(a) For the purpose of 38 U.S.C. 5071-5074, direct grant costs are limited to the Department of Veterans Affairs contribution to the payment of faculty salaries. (§ 17.405(a)(2)(iii).)

(b) For the purposes of 38 U.S.C. 5081-5083 and 5091-5093, direct costs may include in proportion to time and effort spent, but are not limited to, fees and costs directly paid to personnel or for fringe benefits, publications, educational programs, training, or demonstration activities carried out in connection with projects and programs by grantee institutions. In addition, grants made pursuant to 38 U.S.C. 5081-5083 may include costs of construction, provided that such construction is located on land under the jurisdiction of the Secretary and leased to the grantee.

(c) For the purposes of 38 U.S.C. 5081-5083 and 5091-5093, indirect costs may be computed on a percentage basis or on the basis of a negotiated lump-sum allowance in accordance with the principles set forth in the Office of Management and Budget Circulars No. A-88, No. A-87 revised, and No. A-21. In the method of computation used, only indirect costs shall be included which bear a reasonable relationship to the program funded by the grant and shall not exceed a percentage greater than the total institutional indirect cost is of the total direct salaries and wages paid by the institution.

§ 17.412

Additional conditions.

The Secretary of Veterans Affairs may with respect to any grant award impose additional conditions prior to or at the time of any award when in the Secretary's judgment such conditions are necessary to assure or protect advancement of the grant purposes, the interest of the Department of Veterans Affairs or the conservation of grant funds. All construction, and alterations of buildings and structures, related to the award of a grant or other assistance will be subject to section 102(2)(C) of the National Environmental Policy Act.

[46 FR 33523, June 30, 1981]

§ 17.413 Early termination and withholding of payments.

Whenever the Secretary finds that a grantee has failed in a material respect to comply with the applicable provisions of 38 U.S.C. Chapter 82, §§ 17.400 through 17.416, or the terms of the grant, the Secretary may, on

reasonable notice to the grantee withhold further payments and take such other action, including the termination of the grant, as he finds appropriate to carry out the purposes of 38 U.S.C. Chapter 82 and §§ 17.400 through 17.416. Non-cancellable obligations of the grantee properly incurred prior to the receipt of the notice of termination will be honored. The grantee shall be promptly notified of such termination in writing and given the reasons therefor.

[46 FR 33523, June 30, 1981]

§ 17.414 Recapture provision.

(a) If the Secretary determines that any school established with assistance under §§ 17.400 through 17.416:

(1) Is not accredited and fails to gain appropriate accreditation within a reasonable period of time;

(2) Is accredited but fails substantially to carry out the term of the agreement entered into under 38 U.S.C. Chapter 82; or

(3) Is no longer operated for the purpose for which such assistance was granted,

The Secretary shall be entitled to recover from the recipient of assistance the facilities of such school which were established with assistance under §§ 17.400 through 17.416. In order to recover such facilities the Secretary may bring an action in the district court of the United States for the district in which such facilities are situated.

[46 FR 33523, June 30, 1981]

§ 17.415 Right to hearing.

The

in

actions contemplated §§ 17.413 and 17.414 shall not be taken until the grantee has been afforded an opportunity for a hearing. Whenever a hearing is held under this section the procedures shall be in accord with the provisions of §§ 18.9 and 18.10 of this chapter. Failure of a grantee to request a hearing or to appear at a scheduled hearing shall be deemed a waiver of the right to be heard and constitutes consent to the Secretary's decision made on the basis of available information.

[38 FR 26193, Sept. 19, 1973]

§ 17.416 Expansion of hospital education and training capacity.

Expenditures, not to exceed 30 percent of the funds appropriated under 38 U.S.C. 5082 for grants to affiliated medical and other schools, may be made for the extension, expansion, alteration, improvement, remodeling, or repair of Department of Veterans Affairs buildings and structures to make them suitable for use for health manpower education and training. In addition, such expenditures may be made to Department of Veterans Affairs hospitals and facilities for the development or initiation of improved methods of education and training.

[38 FR 26193, Sept. 19, 1973]

(a) Health Services Review Organization (HSRO), the Department of Veterans Affairs' Medical Quality Assurance Program, is a systematic effort by the Department of Veterans Affairs to ensure an optimal level of quality patient care. The HSRO program is an ongoing, efficient, flexible, integrated health care monitoring and improvement system. HSRO shall review the following aspects of medical quality in VA medical facilities:

(1) The appropriateness of patient care and services provided,

(2) The effective utilization of resources,

(3) The safety of patients, and

(4) The conduct or performance of VA employees and others engaged in the provision or support of patient

care.

(b) HSRO is a multifaceted program. (1) Health Services Review Organization-Systematic Internal Review (HSRO-SIR) is an integrated quality assurance process that is internal to each VA Medical Facility.

(2) Health Services Review Organization-Medical District Initiated Peer Review Organization (HSRO-MEDIPRO) is a clinically oriented, medical

district based, peer review system of quality of care and resource utilization assessment to the medical facility.

(3) Health Services Review Organization-Systematic External Review Program (HSRO-SERP) is a systemwide VA review mechanism external to each VA medical facility in which health care evaluators review clinical and administrative aspects of the quality of care in VA medical facilities and the effectiveness of their HSRO-SIR programs.

(4) Health Services Review Organization-Tort Claim Information System (HSRO-TCIS) is a computerized system that contains the peer review of the medical care provided that led to the filing of a tort claim. This system may be maintained at any and all levels of the Veterans Health Services and Research Administration and in the Office of General Counsel and any office under the jurisdiction of the General Counsel.

(c) Corrective action on all medical facility problems or recommendations identified by an HSRO-SIR, HSROMEDIPRO, HSRO-SERP or HSROTCIS review will be initiated and implemented at the lowest possible organizational level through the lines of existing authority.

(d) HSRO-SIR, HSRO-MEDIPRO and HSRO-SERP program activities will be established, conducted and maintained at Veterans Health Services and Research Administration (VHS&RA) organizational levels as prescribed in these regulations and VA policy.

(Authority: 38 U.S.C. 3305)

(e) HSRO-SIR, HSRO-MEDIPRO, HSRO-SERP and HSRO-TCIS program activities will be established, conducted and maintained at VHS&RA organizational levels as prescribed by these HSRO confidentiality regulations and VA policy.

(Authority: 38 U.S.C. 3305)

[47 FR 47010, Oct. 22, 1982, as amended at 54 FR 28668, July 7, 1989; 55 FR 13532, Apr. 11, 1990]

§ 17.501 Administration responsibility.

(a) The Chief Medical Director is responsible for the implementation,

maintenance,

and enforcement of these regulations and will ensure that each VHS&RA organizational element maintains an effective and efficient HSRO program as specified in VA policy.

(b) The Director, Office of Quality Assurance, will provide guidance, oversight, and recommendations to the Chief Medical Director concerning the effectiveness of the HSRO program and the need to make improvements.

(c) Each regional director will ensure that HSRO-MEDIPRO is operational in the region and that clinical care and resource utilization problems unresolved at the district level are acted upon. The regional director will monitor and evaluate the implementation of district HSRO-MEDIPRO plans; review HSRO-MEDIPRO minutes and reviews; approve HSRO-MEDIPRO reports; provide necessary followup on HSRO-MEDIPRO program documents; and approve HSRO-MEDIPRO Board appointments.

(d) Each medical district director is responsbile for implementing and supervising the HSRO-MEDIPRO program within the district and for providing administrative and analytical support. The authority for day-to-day planning, coordination, implementing and monitoring compliance with policies and procedures is delegated to the HSRO-MEDIPRO coordinator. Supervision of the HSRO-MEDIPRO staff will be by the medical district director or designee.

(Authority: 38 U.S.C. 3305)

[54 FR 28669, July 7, 1989]

§ 17.502 [Reserved]

§ 17.503 Individual facility responsibility. (a) Each VA medical facility Director is fully responsible for the HSROSIR program within the facility. The authority for coordinating, training, providing technical support, and conducting day-to-day supervision of HSRO-SIR activities is delegated to the HSRO Coordinator. Supervision of the HSRO Coordinator may be by either the medical facility Director or Chief of Staff as determined by the medical facility Director.

(b) The Chief of Staff and Assistant medical facility Director are responsi

ble for assuring that services under their supervision adequately support and participate in the HSRO-SIR program.

(c) Each Service Chief at a VA medical facility is responsible for planning and implementing HSRO-SIR for his/ her service and ensuring that HSROSIR activities or functions of his/her service are integrated with and supportive of the VA medical facility HSRO-SIR program and meet the intent of the HSRO-SIR plan of the VA medical facility.

(d) The VA medical facility Director will authorize an existing committee or subcommittee to integrate and coordinate HSRO activities. This committee or subcommittee will be composed of VA medical facility employ

ees.

(Authority: 38 U.S.C. 3305)

§ 17.504 Conduct.

(a) Any employee participating in HSRO-SIR, HSRO-SERP, HSROMEDIPRO or HSRO-TCIS program activities will exercise prudent and diligent care and act in good faith while gathering and analyzing factual information prior to making any judgment which may reflect adversely on a VA employee or VA medical facility.

(b) Only those employees in supervisory, executive, or HSRO capacities who have sufficient job related needs to study or otherwise use confidential and privileged records and documents should have access to patient or provider specific identification information or to the confidential coding system. Access to HSRO records within the Department is governed by § 17.527 of this part.

(c) VA employees, upon voluntary or involuntary termination of VA employment for any reason, will not disclose to any person or organization any HSRO records or documents which are designated as confidential and privileged by 38 U.S.C. 3305 and these regulations.

(Authority: 38 U.S.C. 3305)

[54 FR 28669, July 7, 1989, as amended at 55 FR 13532, Apr. 11, 1990]

§ 17.505 HSRO-SIR plan.

Each VA medical facility will develop a written HSRO-SIR plan which establishes responsibilities, defines policy and describes the procedures and mechanisms necessary to maintain an effective HSRO-SIR program. The plan will be reviewed annually as part of the medical facility's evaluation of its HSRO-SIR program, and updated according to need. Each VA medical facility HSRO-SIR plan will identify and address itself to the following subjects:

(a) Philosophy and objectives of the HSRO program (as described

§ 17.500).

(b) Policy statement.

(c) Responsibilities for:

in

(5) Integrating/coordinating information collection and analysis with planning, evaluation and monitoring activities.

(6) Eliminating duplication and nonproductive review activities.

(d) HSRO-SIR functions and elements (as described in § 17.506).

(e) HSRO-SERP and other external reviews.

The plan will be combined with other facility policies and procedures for assuring the quality of patient care to constitute the facility's comprehensive HSRO-SIR program. (Authority: 38 U.S.C. 3305)

§ 17.506 Mandatory HSRO-SIR functions and elements.

The HSRO-SIR plan includes mandatory functions. Each function may contain various elements. Additional HSRO-SIR elements not identified in these HSRO regulations may be included within a function in the HSRO-SIR plan as the VA medical facility Director deems appropriate. However, such additional elements will not be considered a part of the HSROSIR program for purposes of 38 U.S.C. 3305 and these HSRO regulations and

therefore, shall not be considered confidential HSRO records or documents. The five mandatory functions and the elements within these functions are:

(a) Continuous monitoring. (1) Medical records review.

(2) Surgical case (tissue) review. (3) Blood services review.

(4) Therapeutic agents and pharmacy review.

(5) Laboratory review.

(6) Radiology and nuclear medicine review.

(7) Psychiatric program review. (8) Commitment usage analysis. (9) Restraint and seclusion usage analysis.

(10) Infection control review. (11) Surgical and anesthetic compli cations review.

(12) Autopsy review.

(13) Mortality and morbidity review. (14) Review of rejected applications. (15) Patient incident review.

(16) Occurrence screening.

(b) Patient injury control. (1) Reporting.

(2) Quality assurance investigations. (c) Utilization review.

(d) Problem focused health care evaluation studies. This includes special audits of specific problem areas performed at the direction of the VA medical facility Director or Central Office.

(Authority: 38 U.S.C. 3305)

[47 FR 47010, Oct. 22, 1982, as amended at 54 FR 28669, July 7, 1989]

§ 17.507 Description of continuous monitoring.

(a) The continuous monitoring function is a process by which VA medical facility personnel review and objectively assess those clinical activities which are key indicators of the quality of medical care being provided. These clinical activities must be monitored and evaluated on a regular and recurring basis, which may involve reviews on a daily, monthly, quarterly or semiannual basis or as prescribed by VA policy.

(1) All HSRO monitoring techniques, reviews, studies or surveys shall use an appropriate sampling procedure. This methodology does not re