Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 24-03531-09 | Review of Response to Changes in a Patient’s Condition and Quality Reviews at the VA Greater Los Angeles Healthcare System in California | Hotline Healthcare Inspection | ||
1 The VA Greater Los Angeles Healthcare System Director considers conducting peer reviews for the clinical staff involved in the patient’s care from day 30 through day 32, to identify opportunities to strengthen clinical practices and improve the quality of patient care.
2 The VA Greater Los Angeles Healthcare System Director ensures that inpatient nurses receive training on the National Early Warning Signs assessment related to the assessment’s administration, intervention, escalation, and documentation; establishes a process to monitor inpatient nurses’ adherence; and conducts audits to ensure improved and sustained compliance.
3 The VA Greater Los Angeles Healthcare System Director ensures nursing staff have knowledge of and timely access to the accurate names and contact numbers for patients’ on-call provider teams and the medical officer of the day, and addresses and closely monitors discrepancies as warranted.
4 The VA Greater Los Angeles Healthcare System Director reviews [Standard Operating Procedure] SOP-00-QM-100, Clinical and Administrative Escalation Process, May 28, 2025; ensures the procedure meets facility and service-line needs; and confirms information is disseminated to relevant leaders, providers, and nursing staff.
5 The VA Greater Los Angeles Healthcare System Director ensures nursing shift assessments electronic health record documentation is completed, timely, and at frequencies required by Veterans Health Administration’s nursing policies and procedures; takes corrective action as indicated; and establishes a process to monitor for improved and sustained compliance.
6 The VA Greater Los Angeles Healthcare System Director evaluates the circumstances surrounding the death of the patient to ensure completion of comprehensive quality review process(es) in alignment with Veterans Health Administration standards on patient safety and high reliability that identify root causes and provide actions that enhance patient safety and mitigate similar events.
7 The VA Greater Los Angeles Healthcare System Director confirms that facility staff made reasonable efforts to conduct an institutional disclosure with the patient’s family.
Closure Date:
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| 24-03205-235 | Healthcare Facility Inspection of the VA Louisville Healthcare System in Kentucky | Healthcare Facility Inspection | ||
1 The Executive Director oversees improvements to the telephone system to ensure identified vulnerabilities are addressed.
2 Facility leaders ensure exit signs lead to an exit.
3 Facility leaders install detectable warning surfaces anywhere a walkway transitions into a roadway.
4 The Executive Director ensures staff keep patient care areas clean and safe.
5 Facility leaders ensure staff conduct a risk assessment for electrical cord management to identify and implement any needed improvements.
6 The Executive Director ensures staff post biological hazard signs on doors where potentially infectious materials may be present and store clean and dirty items separately.
7 The Executive Director ensures prompt disposal of biohazardous waste.
8 Facility leaders ensure staff conduct a risk assessment on liquid nitrogen use and storage, to include devices in exam rooms, and implement changes accordingly.
9 The Executive Director ensures the Comprehensive Environment of Care Committee identifies at least one facility-specific environment of care trend and establishes a performance improvement plan, including outcome measures, to address it.
10 Facility leaders ensure staff develop service-level workflows for the communication of test results for each service.
11 Facility leaders review the test result communication policy to ensure it complies with the VHA requirement for communicating critical results outside of normal business hours.
12 Facility leaders develop a formal process for staff to track performance metrics for test result communication, implement improvement actions, and report compliance to an appropriate oversight committee.
13 Facility leaders manage panel sizes to ensure patients have timely access to high-quality care.
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| 24-00607-241 | Healthcare Facility Inspection of the VA Detroit Healthcare System in Michigan | Healthcare Facility Inspection | ||
1 Executive leaders ensure staff fix or replace damaged furnishings to allow effective cleaning and disinfection.
2 Executive leaders ensure staff place paper maps at information desks to assist veterans in navigating the facility.
Closure Date:
3 Executive leaders ensure staff store clean equipment in a sanitary environment.
4 Executive leaders ensure hallways and exits are free from obstruction.
5 Executive leaders ensure staff remove defective equipment from clinical areas to prevent use.
6 Executive leaders ensure staff have computer screen privacy filters to protect patients’ personally identifiable information.
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| 24-00392-240 | Inspection of Midwest District 3 Vet Center Operations | Vet Center Inspection Program | ||
1 The District Director ensures district leaders follow the Readjustment Counseling Service policy requirements to provide oversight of morbidity and mortality review panel member assignments and report completion.
2 The District Director identifies reasons for noncompliance with documentation requirements of high-risk client contacts and outcomes in RCSNet and the High Risk Suicide Flag SharePoint site, ensures requirements are met, and monitors compliance.
3 The Readjustment Counseling Service Chief Officer considers developing an additional written policy for High Risk Suicide Flag SharePoint disposition and related RCSNet documentation.
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| 25-00194-239 | Healthcare Facility Inspection of the Eastern Oklahoma VA Health Care System in Muskogee | Healthcare Facility Inspection | ||
1 Facility leaders ensure staff follow facility policies and maintain a cleanenvironment.
2 Facility leaders ensure staff develop service-level workflows for the communication of urgent, noncritical test results.
3 Executive leaders monitor the effectiveness of the patient notification process.
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| 25-00228-214 | Review of Clinical Contact Centers to Assess Leadership and Oversight | Review | ||
1 Require the chief operating officer to direct the Veterans Integrated Service Network directors to fully integrate the core services in accordance with policy to improve operational efficiencies and access for veterans.
2 Establish a process requiring medical facility directors to coordinate with the Office of Integrated Veteran Care and the clinical contact centers before setting up or maintaining a local phone queue for services the clinical contact center provides.
3 Require the Office of Integrated Veteran Care to direct the clinical contact center leaders to determine if schedulers are arbitrarily ending calls in the telephone system to remain in after-call work status longer than needed to reduce the number of calls routed to them.
4 Require the Office of Integrated Veteran Care to review and address inconsistencies in guidance on schedulers’ availability.
5 Direct clinical contact center leaders to routinely evaluate and, if needed, address schedulers’ handle time and availability time to improve performance and reduce inefficiencies.
6 Direct the Office of Integrated Veteran Care to include schedulers’ handle time and availability time as part of VA Health Connect’s annual performance plans to make sure clinical contact centers monitor and address these areas.
7 Make sure the Office of Integrated Veteran Care and chief operating officer evaluate VA Health Connect staffing for scheduling and, if necessary, reallocate staff so all clinical contact centers provide core services and meet required performance standards for scheduling.
8 Direct the Office of Integrated Veteran Care to formalize and clarify internal waiver guidance and include examples of the specific evidence that would be required for a clinical contact center not to provide 24-hour services—such as exploring the use of other strategies like routing calls to another service or partnering with other centers to provide coverage.
9 Ensure the assistant under secretary for health for the Office of Integrated Veteran Care and chief operating officer periodically review the clinical contact center waiver submissions and the planned actions to comply with VA Health Connect requirements.
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| 23-03328-197 | The Accuracy of Veteran Readiness and Employment Claims Cannot Be Assessed Because of Insufficient Documentation | Audit | ||
1 Veteran Readiness and Employment should coordinate with VA’s Office of General Counsel to assess the eligibility decision process and ensure all legal and regulatory requirements are accounted for and confirmed by the appropriate staff. If necessary, Veteran Readiness and Employment should update the process to conform with the general counsel’s interpretation of legal requirements.
2 Veteran Readiness and Employment should develop a standard documentation method for verifying eligibility periods, deferrals, extensions, and final eligibility decisions and train appropriate staff, including vocational rehabilitation counselors, on how to properly document eligibility decisions.
3 Veteran Readiness and Employment should develop a quality assurance review process to monitor the accuracy of eligibility decisions.
4 Veteran Readiness and Employment should coordinate with VA’s Office of General Counsel to assess the entitlement requirements and whether those used to confirm and document entitlement decisions are compliant with laws and regulatory requirements. If changes are needed, Veteran Readiness and Employment should update the manual and train appropriate staff accordingly.
5 Veteran Readiness and Employment should develop additional controls to ensure official entitlement decisions in the narrative report are documented in a manner that is clear and would allow for effective oversight from both internal and external entities, such as containing clear documentation of the assessment of employability factors and additional evidence used to substantiate the claim.
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| 23-03357-156 | Better Controls Needed to Accurately Determine Decisions for Veterans’ Nonpresumptive Conditions Involving Toxic Exposure Under the PACT Act | Review | ||
1 Review all processing errors on cases the Office of Inspector General team identified, correct those errors, and report back on the results of those actions.
2 Collaborate with key stakeholders—such as the VA Secretary and representatives from the Office of Field Operations, the Office of General Counsel, and as needed the Board of Veterans’ Appeals—to prioritize consolidating the guidance for PACT Act claims processing into the Adjudication Procedures Manual.
3 Evaluate the effectiveness of control activities specifically for denials of nonpresumptive conditions under toxic exposure risk activity procedures and determine where new or stronger controls are needed.
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| 24-01092-228 | Widespread Failures in Response to Suspected Community Living Center Resident Abuse at the VA New York Harbor Healthcare System in Queens | Hotline Healthcare Inspection | ||
1 The VA New York Harbor Healthcare System Director reviews facility processes to ensure medical and psychosocial health care for residents who report abuse, and staff are educated on the requirements.
2 The VA New York Harbor Healthcare System Director ensures that community living center nursing leaders and factfinding investigators complete factfindings in accordance with Veterans Health Administration policy.
3 The VA New York Harbor Healthcare System Director reviews responses to other incidents of suspected abuse and ensures actions are completed for resolution, including notifications.
4 The VA New York Harbor Healthcare System Director ensures community living center staff are compliant with Veterans Health Administration Prevention and Management of Disruptive Behavior Program education and training requirements.
5 The VA New York Harbor Healthcare System Director ensures community living center nursing and clinical staffs’ electronic health records documentation meets requirements for timeliness, accuracy, and completion, and takes action as needed.
6 The Under Secretary for Health ensures that VHA abuse policy addresses compliance with federal statutes and regulations, including 42 C.F.R. § 483.12, and outlines suspected elder abuse processes to notify leaders, interdisciplinary care team members, VA Police, patients’ families or designees, and state regulatory agencies; and identifies roles and responsibilities of reviewing officials for investigative reviews.
7 The VA New York Harbor Healthcare System Director ensures system abuse policies include required elements to comply with Veterans Health Administration, state, and federal regulations, including 42 C.F.R. § 483.12; and clearly outlines processes for leaders and staff when responding to suspected abuse related to reporting (for example, to interdisciplinary care team members, VA Police, family or designee, and state regulatory agencies); and conducting factfinding investigations.
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| 24-03608-203 | Inadequate Oversight Allowed a Senior Benefits Representative to Inaccurately Authorize Thousands of Decisions | Review | ||
1 Review all processing errors on cases the OIG review team identified, correct those errors to the extent possible, and report back on the results of those actions.
2 Evaluate the effectiveness of control activities specifically for authorization rate outliers and determine whether new or stronger controls are needed.
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