Recommendations
2124
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 24-00566-16 | Care in the Community Inspection of VA Sierra Pacific Network (VISN 21) and Selected VA Medical Centers | Care in the Community Healthcare Inspection | ||
1 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.
Closure Date:
2 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.
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 Veteran Integrated Service Network Director, in conjunction with facility directors, ensures facility staff scan all community care documents into the patient’s electronic health record within five business days of receipt.
Closure Date:
5 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.
6 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 medical documentation prior to administratively closing consults.
Closure Date:
7 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff make two additional attempts to obtain community providers’ medical documentation within 90 days of the appointment following administrative closure of consults that are not low risk.
Closure Date:
8 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff process community care providers’ requests for additional services within three business days of receipt.
Closure Date:
9 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff send approval or denial letters to community providers for requests for additional services.
Closure Date:
10 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff send approval or denial letters to patients for requests for additional services.
Closure Date:
11 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff schedule patients for community care appointments within seven days of consult entry or receipt in the department.
12 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:
13 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff use the Community Care–Care Coordination Plan note to document all care coordination activities for consults with an assigned level of care other than basic.
Closure Date:
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| 23-01739-26 | Care in the Community Inspection of VA Desert Pacific Healthcare Network (VISN 22) and Selected VA Medical Centers | Care in the Community Healthcare Inspection | ||
1 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 calendar year.
Closure Date:
2 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff complete the operating model staffing tool reassessment every 90 days.
Closure Date:
3 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.
Closure Date:
4 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:
5 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.
6 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff attach diagnostic imaging results to the Community Care Consult Result note.
Closure Date:
7 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:
8 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff make two additional attempts to obtain community providers’ medical documentation within 90 days of the appointment following administrative consult closure.
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 additional services within three business days of receipt.
10 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff incorporate requests for additional services and supporting medical documentation in patients’ electronic health records.
Closure Date:
11 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff verify community care providers’ signatures on requests for additional services forms.
Closure Date:
12 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff send letters to community providers when they deny requests for additional services.
Closure Date:
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| 24-00587-45 | Healthcare Facility Inspection of the VA Southern Oregon Healthcare System in White City | Healthcare Facility Inspection | ||
1 The OIG recommends facility leaders relocate papers and folders outside of patient examination rooms or secure them in protective coverings to mitigate the risk of infection.
Closure Date:
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| 23-03485-03 | VBA Provided Accurate Training on Processing PACT Act Claims but Did Not Fully Evaluate Its Effectiveness | Review | ||
1 Complete level 1 summary reports for the Pension and Fiduciary Service fiscal year 2023 PACT Act training courses and provide feedback from the reports to training staff.
Closure Date:
2 Establish a plan to conduct all four levels of evaluation for PACT Act training and provide feedback to training staff.
Closure Date:
3 Establish deadlines in training evaluation plans for the creation of summary reports.
Closure Date:
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| 24-00608-46 | Healthcare Facility Inspection of the VA Poplar Bluff Health Care System in Missouri | Healthcare Facility Inspection | ||
1 The OIG recommends the Veterans Integrated Service Network Director takes actions to ensure stable and consistent leadership at the facility.
Closure Date:
2 The OIG also recommends Veterans Integrated Service Network leaders assist facility leaders to improve interactions with local union leaders.
Closure Date:
3 The OIG recommends the Interim Medical Center Director ensures all security cameras are operational.
Closure Date:
4 The OIG recommends the Interim Medical Center Director ensures primary care teams are staffed according to Veterans Health Administration guidelines.
Closure Date:
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| 24-00550-32 | Healthcare Facility Inspection of the VA Chillicothe Healthcare System in Ohio | Healthcare Facility Inspection | ||
1 The OIG recommends facility leaders ensure staff understand procedures for cleaning equipment and continue to monitor the physical separation of clean and dirty items in storage spaces.
Closure Date:
2 The OIG recommends that primary care leaders incorporate feedback from primary care staff and include them in process improvement projects.
Closure Date:
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| 24-00390-41 | Inspection of Pacific District 5 Vet Center Operations | Vet Center Inspection Program | ||
1 The District Director, in conjunction with the Deputy District Director, develops a contingency coverage plan to ensure oversight during periods of vet center director vacancies.
Closure Date:
2 The District Director monitors district leaders’ compliance with completion of morbidity and mortality reviews for client deaths by suicide, including timeliness, as required.
Closure Date:
3 The District Director ensures district leaders are aware of the Readjustment Counseling Service policy requirements to provide oversight of morbidity and mortality review completion, including panel member assignments, participation of affected vet center staff, report completion, reporting of completion delays, and information dissemination.
Closure Date:
4 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 assessed at intermediate or high suicide risk levels; and monitors compliance across all zone vet centers.
5 The District Director determines reasons staff did not document providing safety plans to clients, ensures all active clients assessed at intermediate or high suicide risk levels receives a safety plan, and monitors compliance across all zone vet centers.
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| 24-01623-30 | Improvement in the Patient Safety Program with Continued Opportunities to Strengthen Veterans Integrated Service Network 7 Oversight at the Tuscaloosa VA Medical Center in Alabama | Hotline Healthcare Inspection | ||
1 The Veterans Integrated Service Network Director confirms that the patient safety officer reviews investigations by subject matter experts for Joint Patient Safety Reporting events.
Closure Date:
2 The Veterans Integrated Service Network Director provides evidence to demonstrate the Patient Safety Office is completing reviews of a sample of patient safety events that includes analysis of content, recommendations, and required actions, as outlined in Veterans Health Administration Directive 1050.01.
Closure Date:
3 The Veterans Integrated Service Network Director ensures that the Veterans Integrated Service Network 7 Quality and Patient Safety Committee minutes reflect that the patient safety officer conducted analysis of patient safety data to identify opportunities for improvement and provided guidance on facilities’ action plans to address the deficiencies.
Closure Date:
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| 24-00588-19 | Healthcare Facility Inspection of the Birmingham VA Health Care System in Alabama | Healthcare Facility Inspection | ||
1 The OIG recommends that Veterans Integrated Service Network leaders ensure facility staff separate clean and dirty equipment and supplies to prevent cross-contamination.
Closure Date:
2 The OIG recommends Veterans Integrated Service Network leaders ensure facility staff keep the environment clean and safe.
Closure Date:
3 The OIG recommends that executive leaders ensure front desk personnel are competent in communicating with sensory-impaired veterans.
Closure Date:
4 The OIG recommends that facility leaders consistently identify opportunities for improvement, ensure staff implement appropriate action plans, and evaluate actions for sustained improvement.
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| 23-02939-13 | Inadequate Staff Training and Lack of Oversight Contribute to the Veterans Health Administration’s Suicide Risk Screening and Evaluation Deficiencies | National Healthcare Review | ||
1 The Under Secretary for Health ensures that required suicide risk and intervention training includes suicide risk identification screening and evaluation requirements, procedures, and instruction.
Closure Date:
2 The Under Secretary for Health considers establishing benchmarks for suicide risk screening and evaluation that reflect the clinical importance of suicide risk identification requirements and takes action as warranted.
3 The Under Secretary for Health ensures monitoring of adherence to suicide risk identification screening and evaluation setting-specific requirements.
4 The Under Secretary for Health ensures actions taken to address barriers to completing suicide risk screening and evaluation are effective to increase adherence to annual and setting-specific requirements in all clinical settings.
5 The Under Secretary for Health ensures non-mental health clinical specialty leaders are aware of and adherent to the suicide risk identification screening and evaluation requirements.
Closure Date:
6 The Under Secretary for Health ensures clearly identified responsibilities for suicide risk identification screening and evaluation adherence monitoring and oversight.
Closure Date:
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15303