Recommendations
2056
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 24-01859-62 | Mental Health Inspection of the VA Central Western Massachusetts Healthcare System in Leeds | Mental Health Inspection Program | ||
1 The VA Central Western Massachusetts Healthcare System Director establishes a mental health executive council that operates in accordance with VHA requirements.
Closure Date:
2 The VA Central Western Massachusetts Healthcare System Director ensures staff consistently solicit and incorporate veteran feedback into process improvements.
Closure Date:
3 The VA Central Western Massachusetts Healthcare System Chief of Mental Health develops written guidance to ensure staff and veteran safety during outdoor breaks.
Closure Date:
4 The VA Central Western Massachusetts Healthcare System Director ensures the development of written processes for the admission of veterans on an involuntary hold and monitors and tracks compliance with involuntary commitment requirements.
5 The VA Central Western Massachusetts Healthcare System Chief of Staff ensures timely documentation of discussions between the prescriber and veteran on the risks and benefits of newly prescribed medications and monitors for compliance.
Closure Date:
6 The VA Central Western Massachusetts Healthcare System Chief of Staff ensures discharge instructions for veterans include follow-up appointment location and contact information in easy-to-understand language.
7 The VA Central Western Massachusetts Healthcare System Chief of Staff ensures discharge instructions include the purpose for each medication listed and are written in easy-to-understand language.
8 The VA Central Western Massachusetts Healthcare System Chief of Staff ensures staff complete the Columbia-Suicide Severity Rating Scale within 24 hours before discharge and monitors for compliance.
Closure Date:
9 The VA Central Western Massachusetts Healthcare System Chief of Staff ensures staff address ways to make veterans’ environments safer from potentially lethal means in safety plans and monitors for compliance.
Closure Date:
10 The VA Central Western Massachusetts Healthcare System Director ensures staff comply with Skills Training for Evaluation and Management of Suicide requirements and monitors for compliance.
11 The VA Central Western Massachusetts Healthcare System Director establishes an interdisciplinary safety inspection team in alignment with Veterans Health Administration requirements and ensures ongoing compliance.
12 The VA Central Western Massachusetts Healthcare System Chief of Staff ensures that the sally port inpatient unit doors are synchronized and monitors for compliance.
Closure Date:
13 The VA Central Western Massachusetts Healthcare System Director uses VHA guidelines to develop facility-specific policy for the use of restraint chairs.
Closure Date:
14 The VA Central Western Massachusetts Healthcare System Director ensures alignment between physical restraint policies and practices.
15 The VA Central Western Massachusetts Healthcare System Chief of Staff ensures mental health leaders update inpatient unit furniture to meet safety requirements and implements processes to reduce associated safety risks.
Closure Date:
16 The VA Central Western Massachusetts Healthcare System Chief of Staff ensures compliance with VHA requirements for Mental Health Environment of Care Checklist training completion.
Closure Date:
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| 24-01827-57 | Healthcare Inspection VISN Summary Report: Evaluation of Practitioner Credentialing and Privileging for Fiscal Years 2023 to 2024 | National Healthcare Review | ||
1 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures an external practitioner with equivalent specialized training and similar privileges completes solo and two-deep practitioners’ professional practice evaluations in a timely manner.
Closure Date:
2 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network chief medical officers and facility senior leaders, ensures an external practitioner with equivalent specialized training and similar privileges completes Ongoing Professional Practice Evaluations of chiefs of staff in each facility in a timely manner.
3 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors, reviews state licensing board reporting processes at the network level to ensure compliance with Veterans Health Administration policy.
4 The Under Secretary for Health, in conjunction with the Veterans Integrated Service Network 8 Director, ensures the Chief Medical Officer oversees each facility’s annual self-assessment and confirms responses reflect accurate data.
Closure Date:
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| 23-00748-28 | Community Care Network Outpatient Claim Payments Mostly Followed Contract Rates and Timelines, but VA Overpaid for Dental Services | Audit | ||
1 Make sure the Office of Integrated Veteran Care develops contract language and/or maximum allowable rates to limit reimbursements that do not have a Medicare or VA fee schedule rate for Community Care Network claims.
2 Ensure the Office of Integrated Veteran Care improves oversight of healthcare claim payments to prevent, identify, and recover overpayments in a more timely manner.
3 Ensure the Office of Integrated Veteran Care and the Office of Acquisition, Logistics, and Construction, collaborate to extend the contracting officer’s representatives’ designated responsibilities to include monitoring of healthcare invoices.
4 Make sure the Office of Integrated Veteran Care considers including dental contract reimbursement language in the current and/or future contracts that is consistent with other contract healthcare reimbursement methodology to limit dental contract reimbursements, not to exceed the amount the third-party administrators pay the providers.
5 Make certain the Office of Procurement, Acquisition, and Logistics develops sufficient oversight and internal controls over the contract modification process to prevent program overpayments.
6 Require the Office of Veteran Integrated Care and the Office of Acquisition, Logistics, and Construction to collaborate to explore potential recovery of dental payments to Optum.
7 Ensure the Office of Integrated Veteran Care and the Office of Acquisition, Logistics, and Construction collaborate to establish oversight and internal controls for dental services provided through Community Care Network to prevent excessive reimbursements.
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| 24-01535-55 | Staff Mitigated the Impact of Appointment Cancellations in a Mental Health Clinic at the VA Northern Indiana Healthcare System in Fort Wayne | Hotline Healthcare Inspection | ||
1 The VA Northern Indiana Healthcare System Director evaluates the system clinic cancellation policy and Chief of Staff notification of urgent clinic cancellations and takes action as appropriate.
2 The VA Northern Indiana Healthcare System Director reviews short-notice clinical cancellations for social work mental health clinics, including the provider’s clinic, to evaluate patient impact and take actions as appropriate.
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| 24-00103-27 | Financial Efficiency Inspection of the VA Tampa Healthcare System | Financial Inspection | ||
1 Establish a plan to use VA’s cost accounting system information to identify additional ways to reduce costs, enhance efficiency, and inform business decisions as identified by VA financial policy.
2 Ensure the facility has a process to identify cost outliers, such as using the Intermediate Product Cost Outlier report to identify cost outliers that may occur at the healthcare system on a regular basis.
Closure Date:
3 Ensure healthcare system service lines review and update the national labor mapping tool to the Veterans Integrated Service Network managerial cost accounting team as required by VA financial policy to ensure workload is being captured correctly.
4 Ensure that healthcare system staff and responsible finance office staff review all open obligations to ensure balances are valid and should remain open or are closed in a timely manner as required by VA Financial Policy, “Obligations,” as updated in March 2024.
5 Ensure that the healthcare system uses appropriated funds in the manner intended by Congress, as required by the VA Financial Policy, “Obligations,” as updated in March 2024.
6 Consult with the Office of General Counsel and the Office of Acquisitions, Logistics, and Construction to determine whether a bona fide needs or other appropriations law violation occurred and, if any violations did occur, take appropriate remedial and preventive actions to address them.
7 Ensure cardholders comply with prior approval, segregation of duties, and record retention requirements as required by VA Financial Policy, volume 16, chapter 1B, “Government Purchase Card for Micro-Purchases.”
Closure Date:
8 Ensure cardholders and approving officials are aware of the requirement to review purchases and determine when it is in the best interest of the government to use strategic sourcing.
Closure Date:
9 Develop and implement a plan to ensure data accuracy and reliability in the Generic Inventory Package and ensure processes are in place to monitor performance metrics in accordance with Veterans Health Administration policy.
Closure Date:
10 Develop and maintain an effective standardized training program for new and current inventory staff and monitor the staff’s knowledge and skill level.
11 In coordination with the Strategic Acquisition Center, ensure that the Medical Surgical Prime Vendor facility-level contracting officer’s representatives and ordering officers are appointed and delegated properly and perform all required duties according to the scope and limitation of the designee’s authority.
Closure Date:
12 In coordination with the Strategic Acquisition Center, submit ratifications for any Medical Surgical Prime Vendor unauthorized commitments in accordance with the Federal Acquisition Regulation.
Closure Date:
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| 24-00549-56 | Healthcare Facility Inspection of the VA Salem Healthcare System in Virginia | Healthcare Facility Inspection | ||
1 The Executive Director mitigates the impact of construction on patient care in the Emergency Department.
2 The Chief of Staff ensures the toxic exposure screening navigators verify data to track veterans waiting for secondary screenings and address any backlog.
Closure Date:
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| 24-01219-12 | Lapse in Fiduciary Program Oversight Puts Some Vulnerable Beneficiaries at Risk | Review | ||
1 Establish Veterans Benefits Management System–Fiduciary records for the 311 identified beneficiaries within the Veterans Benefits Management System.
Closure Date:
2 Start or resume required oversight activities, such as field examinations, to assess the well-being and protection of VA funds for the 311 identified beneficiaries.
Closure Date:
3 Implement controls to identify when beneficiaries deemed incompetent do not have electronic fiduciary records and to ensure records are established in the required system(s).
Closure Date:
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| 24-00234-53 | Deficiencies in Invasive Procedure Complexity Infrastructure, Surgical Resident Supervision, Information Security, and Leaders’ Response at the Lieutenant Colonel Charles S. Kettles VA Medical Center in Ann Arbor, Michigan | Hotline Healthcare Inspection | ||
1 The Lieutenant Colonel Charles S. Kettles VA Medical Center Director ensures that service chiefs responsible for required invasive procedure infrastructure services ensure the completion of the annual review of infrastructure and that existing infrastructure is accurately reported.
Closure Date:
2 The VA Healthcare System Serving Ohio, Indiana, and Michigan Network Director ensures that requirements and processes for invasive procedure complexity infrastructure waiver requests are clearly communicated to facility leaders.
Closure Date:
3 The VA Healthcare System Serving Ohio, Indiana, and Michigan Network Director reviews the process for tracking invasive procedure complexity infrastructure waiver requests, and takes actions as needed to avoid delays in review and submission.
Closure Date:
4 The Under Secretary for Health ensures that guidance provided to Veterans Integrated Service Network and facility leaders regarding the invasive procedure complexity infrastructure waiver request process is clear and consistent with Veterans Health Administration Directive 1220(1).
5 The Lieutenant Colonel Charles S. Kettles VA Medical Center Director confirms that acute and emergent patient transfer times related to waived infrastructure requirements are tracked and monitored, identifies trends or adverse patient outcomes, and takes actions as warranted.
6 The Lieutenant Colonel Charles S. Kettles VA Medical Center Director directs the chief of surgery, or designee, to attend blood utilization review committee meetings per facility requirements, and ensures compliance.
7 The Lieutenant Colonel Charles S. Kettles VA Medical Center Director reviews the care provided to patient B to confirm compliance with Veterans Health Administration Directive 1004.08, determines if an institutional disclosure is warranted, and takes action as required.
Closure Date:
8 The Under Secretary for Health reviews Veterans Health Administration Directive 1400.01 to confirm that the supervision of PGY-1 surgery residents and guidance provided to Veterans Health Administration facilities aligns with Veterans Health Administration policy and Accreditation Council for Graduate Medical Education program requirements.
9 The Lieutenant Colonel Charles S. Kettles VA Medical Center Director ensures that operative documentation is completed per facility policy, reviews the methodology for monitoring operative documentation compliance, and takes action as necessary.
Closure Date:
10 The Lieutenant Colonel Charles S. Kettles VA Medical Center Director reviews and monitors staff and health professional trainee compliance with the rules of behavior as it applies to authorized access to all VA computer programs including clinical applications.
Closure Date:
11 The Under Secretary for Health evaluates the process for granting authorized access to VA computer systems for health profession trainees and takes steps to ensure access is provided by the start of trainee rotations at VA facilities.
12 The VA Healthcare System Serving Ohio, Indiana, and Michigan Network Director ensures the corrective actions developed by facility leaders to address surgical intensive care unit patient safety concerns are completed and evaluated for effectiveness.
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| 23-01609-14 | Atlanta Call Center Staffing and Operational Challenges Provide Lessons for the New VISN 7 Clinical Contact Center | Review | ||
1 Use up-to-date contact center data and the recommended Veterans Health Administration call center staffing model to ensure the clinical contact center is operating within indicated target staffing goals.
2 Evaluate call center staffing and call data for clinical contact center staff based at the Atlanta facility to identify possible operational inefficiencies related to scheduling, handle time, and availability for calls, and address inefficiencies as needed.
3 Periodically evaluate the performance of health administration services staff who answer specialty care clinic calls at the Atlanta facility to ensure they meet Veterans Health Administration call center performance standards.
4 Evaluate call data to ensure health administration services staff at the Atlanta facility who answer calls for the mental health and specialty care clinics meet Veterans Health Administration call center performance standards for timeliness and abandonment rate.
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| 24-01598-43 | Deficiencies in Case Management and Access to Care for HUD-VASH Veterans at the VA Greater Los Angeles Healthcare System in California | Hotline Healthcare Inspection | ||
1 The Greater Los Angeles Healthcare System Director ensures veterans enrolled in the Housing and Urban Development Veterans Affairs Supportive Housing program have documented treatment plans consistent with Veterans Health Administration and facility policy.
2 The Greater Los Angeles Healthcare System Director reviews and assesses the Housing and Urban Development Veterans Affairs Supportive Housing program supervisors’ electronic health record review process to assess Housing and Urban Development Veterans Affairs Supportive Housing-related documentation, including treatment plan deficiencies, and takes action as warranted.
3 The Greater Los Angeles Healthcare System Director ensures facility Housing and Urban Development Veterans Affairs Supportive Housing program discharge policy is in alignment with Veterans Health Administration policy.
4 The Greater Los Angeles Healthcare System Director reviews and assesses the Housing and Urban Development Veterans Affairs Supportive Housing program supervisors’ process to identify incongruencies between electronic health records and Homeless Operations Management and Evaluation System documentation, and takes action as warranted.
5 The Greater Los Angeles Healthcare System Director reviews patient aligned care team assignments for unhoused Housing and Urban Development Veterans Affairs Supportive Housing veterans, and takes action as warranted.
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