Care in the Community Inspection of Medical Facilities in VISN 10: VA Healthcare System Serving Ohio, Indiana, and Michigan

Report Information

Issue Date
Report Number
24-00824-174
VISN
10
State
Indiana
Kentucky
Michigan
Ohio
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Care in the Community Healthcare Inspection
Report Topic
Care Coordination
Community Care
Major Management Challenges
Healthcare Services
Recommendations
16
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary

This Office of Inspector General (OIG) Care in the Community healthcare inspection program report describes the results of a focused evaluation of community care processes at eight Veterans Integrated Service Network (VISN) 10: VA Healthcare System Serving Ohio, Indiana, and Michigan medical facilities with a community care program. 

This evaluation focused on five domains:
   •    Leadership and Administration of Community Care
   •    Administratively Closed Community Care Consults
   •    Community Care Provider Requests for Additional Services
   •    Care Coordination Activities for Patients Referred for Community Care
   •    Community Urgent Care Coordination and Management

The OIG issued 16 recommendations for VA to correct identified deficiencies in the five domains:
   •    Leadership and Administration of Community Care
     o    Community oversight councils
     o    Community care clinical staffing needs
     o    Patient safety events
     o    Patient safety trends, lessons learned, and corrective actions
     o    Community care document importing
   •    Administratively Closed Community Care Consults
     o    Community care appointment confirmation
     o    Medical documents
   •    Community Care Provider Requests for Additional Services
     o    Request processing
     o    Request incorporation in the electronic health record
     o    Provider signature verification
     o    Approval letters for community providers and patients
   •    Care Coordination Activities for Patients Referred for Community Care
     o    Community Care–Care Coordination Plan note use to document care coordination activities
     o    Appointment attendance confirmation
   •    Community Urgent Care Coordination and Management
     o    Urgent care visit notification process
     o    Community Care–Urgent Care Record note creation

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures community care oversight councils function according to their charters and meet the required number of times per fiscal year.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/29/2025

The Veterans Integrated Service Network Director, in conjunction with facility directors, confirms community care clinical staffing needs and takes action as necessary.

No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff enter community care patient safety events into the Joint Patient Safety Reporting system.

No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures patient safety managers or designees brief community care patient safety event trends, lessons learned, and corrective actions at community care oversight council meetings.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/29/2025

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures staff import all community care documents into patients’ electronic health records within five business days of receipt.

No. 6
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff confirm patients attended their appointments and attempt to obtain community providers’ medical documents prior to administratively closing consults.

No. 7
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff make two attempts to obtain community providers’ medical documents within 90 days of the appointment following administrative closure of non-low-risk consults.

No. 8
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff process community providers’ requests for additional services within three business days of receipt.

No. 9
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff incorporate supporting medical documents with requests for additional services forms into patients’ electronic health records.

No. 10
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff confirm community providers signed the requests for additional services forms.

No. 11
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff send approval letters to community providers for requests for additional services.

No. 12
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff send approval letters to patients for requests for additional services.

No. 13
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff create and use the Community Care–Care Coordination Plan note to document all care coordination activities for consults with an assigned level of care coordination other than basic.

No. 14
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff confirm patients attended their scheduled community care appointments and received care.

No. 15
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

Veterans Health Administration creates a process for facility staff notification of patients’ urgent care visits in the community.

No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/29/2025

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff create the Community Care–Urgent Care Record note in electronic health records when they receive urgent care documents.