Recommendations
2056
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 22-04108-235 | Inspection of Select Vet Centers in Continental District 4 Zone 2 | Vet Center Inspection Program | ||
1 District leaders and the Jackson and Corpus Christi Vet Center Directors collaborate with the support VA medical facility to determine reasons for noncompliance with staff participation on the mental health executive council, take action as indicated, and monitor compliance.
Closure Date:
2 District leaders and the Fort Worth Vet Center Director determine reasons for noncompliance with Readjustment Counseling Service documentation standards, ensure completion, and monitor compliance.
3 District leaders and the Fayetteville, New Orleans, Jackson, Corpus Christi, Fort Worth, and San Antonio Northeast Vet Center Directors determine reasons for noncompliance with completing four hours of external clinical consultation for clinically complex cases per month, ensure a process is implemented, and monitor compliance.
Closure Date:
4 District leaders and the Jackson and San Antonio Northeast Vet Center Directors determine reasons for noncompliance with Vet Center Directors review of 10 percent of active client records monthly for each counselor’s caseload, ensure completion, and monitor compliance.
Closure Date:
5 District leaders and the Fayetteville, New Orleans, Jackson, Corpus Christi, Fort Worth, and San Antonio Northeast Vet Center Directors determine reasons for noncompliance with employees completing select trainings in the required time frame, ensure completion, and monitor compliance.
Closure Date:
6 District leaders and the Fayetteville, New Orleans, Jackson, Corpus Christi, Fort Worth, and San Antonio Northeast Vet Center Directors determine reasons for noncompliance with completion of an outreach plan with all required strategic components, ensure completion, and monitor compliance.
Closure Date:
7 District leaders and the Fayetteville Vet Center Director determine reasons for noncompliance with having an annual risk and vulnerability assessment completed by VA police or local law enforcement, ensure completion, and monitor compliance.
Closure Date:
8 District leaders and the New Orleans Vet Center Director determine reasons for noncompliance with monthly fire extinguisher inspections, ensure completion, and monitor compliance.
Closure Date:
9 District leaders and the New Orleans, Jackson, and Corpus Christi Vet Center Directors determine reasons for noncompliance with monthly automated external defibrillator inspections, ensure completion, and monitor compliance.
Closure Date:
10 District leaders and the Fayetteville and Fort Worth Vet Center Directors determine reasons for noncompliance with having an emergency and crisis plan that includes required components, ensure completion, and monitor compliance.
Closure Date:
11 District leaders and the Fayetteville, Corpus Christi, Fort Worth, and San Antonio Northeast Vet Center Directors determine reasons for noncompliance with a desktop reference sheet outlining steps for ancillary office staff to follow in case of a suicidal or homicidal client, ensure completion, and monitor compliance.
Closure Date:
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| 22-04107-236 | Inspection of Select Vet Centers in Continental District 4 Zone 1 | Vet Center Inspection Program | ||
1 District leaders and the Fort Collins, Kalispell, Abilene, Salt Lake City, and Cheyenne Vet Center Directors collaborate with the support VA medical facility to determine reasons for noncompliance with staff participation on the mental health executive council, take action as indicated, and monitor compliance.
Closure Date:
2 District leaders and the Fort Collins, Tulsa, Abilene, Salt Lake City, and Cheyenne Vet Center Directors determine reasons for noncompliance with completing four hours of external clinical consultation for clinically complex cases per month, ensure a process is implemented, and monitor compliance.
Closure Date:
3 District leaders and the Fort Collins, Abilene, and Salt Lake City Vet Centers Directors determine reasons for noncompliance with Vet Center Directors review of 10 percent of active client records monthly for each counselor’s caseload, ensure completion, and monitor compliance.
Closure Date:
4 District leaders and the Fort Collins, Kalispell, Tulsa, Abilene, Salt Lake City, and Cheyenne Vet Center Directors determine reasons for noncompliance with employees completing select trainings in the required time frame, ensure completion, and monitor compliance.
Closure Date:
5 District leaders and the Fort Collins, Kalispell, Tulsa, Abilene, Salt Lake City, and Cheyenne Vet Center Directors determine reasons for noncompliance with completion of an outreach plan with all required strategic components, ensure completion, and monitor compliance.
Closure Date:
6 District leaders and the Cheyenne Vet Center Director determine reasons for noncompliance with completion of an annual fire or safety inspection, ensure completion, and monitor compliance.
Closure Date:
7 District leaders and the Abilene and Cheyenne Vet Center Directors determine reasons for noncompliance with having an annual risk and vulnerability assessment completed by VA police or local law enforcement, ensure completion, and monitor compliance.
Closure Date:
8 District leaders and the Fort Collins and Kalispell Vet Center Directors determine reasons for noncompliance with monthly fire extinguisher inspections, ensure completion, and monitor compliance.
Closure Date:
9 District leaders and the Salt Lake City Vet Center Director determine reasons for noncompliance with annual fire extinguisher servicing, ensure completion, and monitor compliance.
Closure Date:
10 District leaders and the Fort Collins, Kalispell, Abilene, Salt Lake City, and Cheyenne Vet Center Directors determine reasons for noncompliance with monthly automated external defibrillator inspections, ensure completion, and monitor compliance.
Closure Date:
11 District leaders and the Salt Lake City Vet Center Director determine reasons for noncompliance with annual automated external defibrillator servicing by VA medical center biomedical engineering, ensure completion, and monitor compliance.
Closure Date:
12 District leaders and the Cheyenne Vet Center Director determine reasons for noncompliance with building evacuation plans posted in a communal area for staff and visitors, ensure completion, and monitor compliance.
Closure Date:
13 District leaders and the Fort Collins Vet Center Director determine reasons for noncompliance with a desktop reference sheet outlining steps for ancillary office staff to follow in case of a suicidal or homicidal client, ensure completion, and monitor compliance.
Closure Date:
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| 22-04109-238 | Inspection of Continental District 4 Vet Center Operations | Vet Center Inspection Program | ||
1 The District Director monitors compliance with leaders’ completion of morbidity and mortality reviews for client deaths by suicide, including timeliness, as required.
Closure Date:
2 The District Director determines reasons vet center counselors did not complete safety plan components for clients assessed at intermediate or high suicide risk level in either acute, chronic, or both categories; ensures completion of safety plans for all active clients assesses at intermediate or high suicide risk levels; and monitors compliance across all zone vet centers.
Closure Date:
3 The District Director determines reasons staff did not document providing safety plans to clients, ensures that a safety plan was provided to all active clients assessed at intermediate or high suicide risk levels, and monitors compliance across all zone vet centers
Closure Date:
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| 23-00925-227 | Veterans Crisis Line Implementation of 988 Press 1 Preparation and Leaders' Response | National Healthcare Review | ||
1 The Veterans Crisis Line Director determines the optimal ratio of supervisors to frontline staff needed, makes the best efforts to ensure the ratio is maintained, and takes action as warranted.
Closure Date:
2 The Veterans Crisis Line Director ensures supervisors and staff are aware of postvention resources and monitors for compliance.
Closure Date:
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| 23-01965-217 | Incomplete Implementation of Corrective Actions to Address Pharmacy Service Concerns at the VA Central Western Massachusetts Healthcare System in Leeds | Hotline Healthcare Inspection | ||
1 The Veterans Integrated Service Network Director ensures thorough completion of the VA Central Western Massachusetts Healthcare System pharmacy corrective actions, and takes action as needed.
Closure Date:
2 The Veterans Integrated Service Network Director ensures that pharmacy supervisors and staff at the VA Central Western Massachusetts Healthcare System receive the necessary training and written guidance to complete the corrective actions, and monitors for compliance.
Closure Date:
3 The Veterans Integrated Service Network Director ensures that leaders, whose actions contributed to the incomplete corrective actions and ineffective oversight, receive administrative action, as appropriate.
Closure Date:
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| 23-01583-183 | Ineffective Oversight of Community Care Providers’ Special-Authorization Drug Prescribing Increased Pharmacy Workload and Veteran Wait Times | Audit | ||
1 Require the Office of Integrated Veteran Care and Pharmacy Benefits Management Services to improve community provider compliance when prescribing special-authorization drugs and being responsive to VA pharmacy inquiries. This should include consideration of electronic system capabilities to attach medical justifications, allow community providers to have real-time access to VA’s formulary when prescribing drugs, and enable two-way communication between community providers and VA pharmacists electronically.
Closure Date:
2 Task the Office of Integrated Veteran Care to train community providers on the VA formulary and implement a process to improve tracking of training completion and community providers’ compliance with VA guidance on submitting prescriptions for special-authorization drugs.
3 Direct Pharmacy Benefits Management Services to update its dashboard to more accurately capture special-authorization drug request processing times and provide the Office of Integrated Veteran Care access to this information for contract management purposes.
Closure Date:
4 Instruct Pharmacy Benefits Management Services to require that VA pharmacy personnel document community care prescriptions for special-authorization drugs in the veteran’s medical record (in consults when applicable or medical notes) when the pharmacy receives the prescription and make clear that the 96-hour processing time is a requirement for these types of drug requests.
Closure Date:
5 Require Pharmacy Benefits Management Services to routinely remind pharmacists that they are responsible for reporting a community provider to the medical facility’s community care office when the provider does not comply with VA documentation requirements for special-authorization drug requests.
Closure Date:
6 Charge facility community care offices to work with pharmacy personnel to report when they receive information from VA pharmacists that community providers did not comply with VA’s documentation requirements for special-authorization drugs. Reporting mechanisms can include submitting Potential Quality Issue Referral reports or Health Care Quality Concern reports to third-party administrators.
Closure Date:
7 Direct Pharmacy Benefits Management Services to standardize requirements for how VA pharmacists code drug requests from community providers in the electronic system that were canceled, rejected, or removed to help VHA determine if corrective actions need to be taken on processes, contract terms, or guidance.
Closure Date:
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| 23-01737-205 | Care in the Community Inspection of VA MidSouth Healthcare Network (VISN 9) and Selected VA Medical Centers | Care in the Community Healthcare Inspection | ||
1 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures employees complete the operating model staffing tool reassessment every 90 days.
Closure Date:
2 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff report community care patient safety events in the Joint Patient Safety Reporting system.
Closure Date:
3 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.
Closure Date:
4 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures VHA staff scan all community care documents into the patient’s electronic health record within five business days of receipt.
5 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility staff attach community diagnostic imaging results to the designated Community Care Consult Result note.
Closure Date:
6 The Veterans Integrated Service Network Director, in conjunction with facility directors, requires facility community care staff to use the significant findings alert to notify the ordering provider of abnormal diagnostic imaging results.
Closure Date:
7 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff make required attempts to obtain medical documentation within 90 days of the appointment after administratively closing consults without medical documentation.
Closure Date:
8 The Veterans Integrated Service Network Director, in conjunction with facility directors, requires facility community care staff to use the significant findings alert when they administratively close community care consults without medical documentation.
Closure Date:
9 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff process community care providers’ requests for services within three business days of receipt.
10 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff assign a level of care coordination to all community care consults as required.
Closure Date:
11 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 for documenting all care coordination activities for consults with an assigned level of care other than basic.
12 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff change the status of community care consults to active within two business days of the consult’s initial entry or date forwarded to community care staff.
Closure Date:
13 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff schedule patients for community care appointments within the required time frames.
14 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff confirm patients attended scheduled community care appointments and received care.
Closure Date:
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| 23-00539-221 | A Select Review of VHA’s Implementation of the VA Sustainability Plan | National Healthcare Review | ||
1 The Secretary of Veterans Affairs considers incorporating environmental stewardship values into the goals of the Climate- and Sustainability-Focused Federal Workforce priority action in the VA Sustainability Plan to align with Executive Order 14057.
Closure Date:
2 The Under Secretary for Health evaluates the facility-level Green Environmental Management System program manager position, and determines the position’s responsibilities, if any, in the implementation of the VA Sustainability Plan.
Closure Date:
3 The Under Secretary for Health considers broadening the scope of training, education, and engagement of Veterans Health Administration’s workforce to include and incorporate environmental stewardship values.
Closure Date:
4 The Under Secretary for Health encourages continued efforts by the Veterans Health Administration National Anesthesia Service to track and reduce greenhouse gas emissions from inhalational anesthetics and considers evaluation and implementation of a comprehensive waste anesthetic gas mitigation strategy, in pursuit of the VA Sustainability Plan’s priority action goal of achieving net-zero greenhouse gas emissions by 2045.
Closure Date:
5 The Under Secretary for Health considers the relative merits of single-use versus reusable medical devices and evaluates current Veterans Health Administration policy that prohibits the repurposing of single-use medical devices by VA medical centers to increase landfill waste diversion.
Closure Date:
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| 23-03531-218 | Failures by Telemetry Medical Instrument Technicians and Leaders’ Response at the VA Eastern Colorado Health Care System in Aurora | Hotline Healthcare Inspection | ||
1 The VA Eastern Colorado Health Care System Director evaluates and ensures that telemetry medical instrument technicians and registered nurses comply with Veterans Health Administration and facility policy requirements for documentation and scanning, specifically related to telemetry oxygenation and rhythm strips and change in patient condition.
2 The VA Eastern Colorado Health Care System Director in conjunction with telemetry nursing leaders, ensures completion of a comprehensive review of the telemetry program and documented oversight of compliance with medical instrument technician monitoring expectations, identifies deficiencies, and takes actions as warranted.
Closure Date:
3 The VA Eastern Colorado Health Care System Director promotes and encourages all staff to use the Joint Patient Safety Reporting system to report patient safety events and ensures telemetry staff and managers are trained on the use of the Joint Patient Safety Reporting system.
Closure Date:
4 The VA Eastern Colorado Health Care System Director evaluates and ensures quality and patient safety event review processes comply with Veterans Health Administration guidance, specifically regarding rejection and follow-up of patient safety reports.
Closure Date:
5 The VA Eastern Colorado Health Care System Director and facility leaders meet all Veterans Health Administration requirements for institutional disclosures for events meeting institutional disclosure criteria.
Closure Date:
6 The VA Eastern Colorado Health Care System Director ensures review of facility clinical alarm management and committee processes, identifies deficiencies, and takes actions as warranted.
Closure Date:
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| 23-00749-171 | Unauthorized Community Care Dental Procedures Risked Improper Payments | Audit | ||
1 Ensure all community dentists who provide dental care to veteran patients are notified and periodically reminded of the preauthorization requirements for any changes to treatment plans.
Closure Date:
2 Conduct expanded postpayment reviews to identify and recover payments for unauthorized dental procedures.
Closure Date:
3 Monitor VA dentists to make sure they include required dental procedure codes, not only general descriptions or Standardized Episodes of Care, on referrals to identify the procedures community dentists are authorized to perform.
Closure Date:
4 Review the current contract language and determine if there is a need to clarify the third-party administrators’ claims adjudication responsibilities in its contracts to include the identification of unauthorized dental procedures and adjudication of possible denials of payment or implement controls within VA that will perform this adjudication function for dental claims.
5 Enable the Office of Finance’s automated payment system to deny payment for community dental services if the procedure codes on the dental claims do not fall within the Standardized Episodes of Care on the referral.
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