All Reports

The Marion VA Health Care System Director ensures a review is conducted of the care provided to the patient by the primary care provider and the neurologist, consults with Human Resources and General Counsel Offices, and takes action as warranted. 

The Marion VA Health Care System Director ensures primary care nursing staff’s adherence to facility fall prevention policy and monitors compliance.

The Marion VA Health Care System Director evaluates the facility fall prevention policy to consider expectations for mental health staff’s role in responding to patient reports of falls at home. 

The Marion VA Health Care System Director reviews processes to ensure primary care and specialty care staff are appropriately educated and trained on making referrals to and the services available through the facility’s Traumatic Brain Injury Polytrauma Clinic.

The Marion VA Health Care System Director ensures compliance with the primary care program facility policy concerning specialty consultation staff’s communication with a patient’s primary care provider regarding patient concerns.

The Marion VA Health Care System Director ensures compliance with the facility patient problem list standard operating procedure. 

The Marion VA Health Care System Director strengthens processes to ensure compliance with Veterans Health Administration timeliness standards for obtaining and scanning community care records.

The Marion VA Health Care System Director reviews facility care coordination practices between primary care providers and community care providers, identifies barriers to sharing patient treatment information to inform clinical decision-making, and takes action as warranted. 

The Marion VA Health Care System Director ensures community care staff adhere to requirements regarding completion of community care-care coordination plan notes and monitors compliance.

The Marion VA Health Care System Director conducts a review of the facility primary care scheduling processes to ensure compliance with Veterans Health Administration and facility policy on care coordination within Patient Aligned Care Teams. 

The Marion VA Health Care System Director ensures suicide prevention staff document high-risk flag inactivation within patients’ electronic health records and notify patients when a high-risk flag is activated or inactivated as required by the Veterans Health Administration, and monitors compliance.

The Marion VA Health Care System Director ensures mental health staff adhere to Veterans Health Administration requirements on safety planning during high risk for suicide patient record flag patient contacts.

The Marion VA Health Care System Director evaluates the care provided to the patient, determines if an institutional disclosure is warranted, and takes action as indicated.

The Executive Director ensures each service has a service-level workflow for test result communication.

The Executive Director reviews current practices to obtain documents from community providers and determines if leaders can standardize an approach to improve timeliness.

The VA Boston Healthcare System Director assesses the timeliness of appointment setting for VA direct and community care referrals and ensures facility staff establish appointments within required time frames.

The VA Boston Healthcare System Director reviews consult management practices and ensures the proper use of consults for VA direct care referrals.

The VA Boston Healthcare System Director reviews appointment wait times and acts on identified opportunities for improvement.

The VA Fayetteville Coastal Healthcare System Director reviews the endocrine consult management process and takes actions as needed to ensure compliance with current Veterans Health Administration directives and guidance.

The VA Fayetteville Coastal Healthcare System Director implements a strategy to review patients affected by delayed endocrine consults to evaluate whether harm occurred and the appropriateness of institutional disclosures.

The VA Fayetteville Coastal Healthcare System Director ensures a sustainable and effective service line agreement between endocrine and primary care services is developed and agreed upon by both services, and monitors implementation.

The VA Fayetteville Coastal Healthcare System Director confirms effective utilization of endocrine clinic appointments to ensure timely access to care.

The VA Fayetteville Coastal Healthcare System Director ensures a process is in place for monitoring and tracking clinic profile modification requests.

The VA Mid-Atlantic Health Care Network Director reviews the leadership performance of the chief of medicine related to communication and collaboration and takes action as necessary.

The VA Fayetteville Coastal Healthcare System Director evaluates communication gaps identified in this report between leaders of primary care and the Medicine Service and takes action to ensure consistency with Veterans Health Administration High Reliability Organization goals.

Establish and use agreements with other VA medical facilities to help identify and schedule direct care when services are unavailable at a veteran’s local VA facility.

At least annually, emphasize to schedulers the proper methods (including the use of codes) to document when veterans opt out of community care.

Require the medical facility director at the Jesse Brown VA Medical Center in Chicago to make sure veterans who request mental health services are assessed for community care and informed of all potential care options.

Require medical facility directors in Veterans Integrated Service Network 12 to review and process consults initiated in the first quarter of fiscal year 2024 that remain in a pending, active, or scheduled status.

Evaluate which staff should have access to and should update the Consult Toolbox when records are requested or received and update the “Consult Business Rules and Uses of the Consult Package Standard Operating Procedure” to reflect necessary changes.

Include controls within the Consult Toolbox to prevent errors and improve data quality, including controls on administrative closure of low-risk consults and documenting the records-retrieval method.

Update consult closure policies and procedures to clarify requirements for administrative closure and determine whether metrics for the percentage of records received should be a requirement and included in policy.

Determine whether Veterans Health Administration facilities’ community care offices should continue to be required to use the administrative closure report for oversight of administratively closed consults, and if not, determine what reports should be required.

Evaluate the workload of community care staff to determine the most efficient way to structure and execute their duties.

Determine if there are mechanisms to identify standardization opportunities and increase efficiency for improving records return processes.

Ensure community care staff follow procedures to reduce duplicate records received.

Evaluate ways to increase use of provider electronic records portals to reduce reliance on electronic fax when retrieving medical records.

Consider increased implementation of technologies to improve records processing once received to reduce the manual renaming of electronic files and uploading of records into the electronic health record.

Ensure records from the Joint Longitudinal Viewer are uploaded into the electronic health record.

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.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care leaders complete the staffing tool reassessment every 90 days.

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

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.

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.

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.

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 documents within 90 days of the appointment following administrative closure of non-low-risk consults.

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.

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.

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.

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 in the electronic health record to document all care coordination activities for consults with an assigned level of care coordination other than basic.

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.

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 the electronic health record when they receive urgent care documents.

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.

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

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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

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.

The Under Secretary for Health assesses the feasibility of the 7-day appointment scheduling requirement for Care in the Community consults and considers stratifying the time frame requirement according to risk.

The VA Maryland Health Care System Director develops and implements an education plan to address incomplete Care in the Community consult submissions and monitors efficacy of the plan.

The VA Maryland Health Care System Director implements Care in the Community consult management process improvements, focusing on consult completion.

The Veterans Integrated Service Network Director assists system leaders with completing corrective actions to improve Care in the Community performance.

The VA Maryland Health Care System Director ensures system Care in the Community staff create and use care coordination plan notes for documenting all care coordination activities for consults with an assigned level of care other than basic and monitors for compliance.

The VA Maryland Health Care System Director ensures full implementation of Veterans Health Administration’s enhanced Referral Coordination Initiative as required and monitors for compliance.

The VA Maryland Health Care System Director ensures Care in the Community Patient Advocate Tracking System data is analyzed for use in service-level quality and process improvement and monitors for compliance.

The VA Eastern Kansas Healthcare System Director ensures the chief of primary care reviews, strengthens, and implements system Patient Aligned Care Team processes for tracking and following up on community care consults ordered, particularly diagnostic consults, to verify patients receive care and to review and act upon consult results, as clinically indicated.

The VA Eastern Kansas Healthcare System Director reviews institutional disclosures conducted by the system over the past 12 months, including the patient’s institutional disclosure, and ensures these disclosures fully adhere to Veterans Health Administration Directive 1004.08, Disclosure of Adverse Events to Patients, October 31, 2018, including documenting the details of the adverse event and discussion points of the disclosure, and takes action needed to remediate disclosures that do not meet these standards.

The VA Eastern Kansas Healthcare System Director ensures community care staff make the required three attempts to obtain patients’ community care records within 90 days of completed appointments, and monitors for compliance.

The VA Eastern Kansas Healthcare System Director collaborates with the Kansas City VA Medical Center Director to review the frequency and circumstances of community care records being sent to the incorrect VA facility, develops, and implements a process for ensuring community care records are delivered to the correct ordering VA facility, educates staff on the process, and monitors for compliance.

The Under Secretary for Health establishes and monitors compliance with a process that ensures the Veterans Health Administration ordering provider receives urgent non-life-threatening abnormal test results from care obtained in the community, such as the diagnostic positron emission tomography scan results described in this report, within a time frame that allows timely attention and appropriate action to be taken.

The Veterans Integrated Service Network Director, in conjunction with the Veterans Health Administration National Center for Lung Cancer Screening Program Office, evaluates the VA Eastern Kansas Healthcare System’s Lung Cancer Screening Program to ensure operational adherence to the Lung Cancer Screening Program requirements, and takes action as needed.

Review the Veterans Health Administration’s current methods, assumptions, and approaches used to project medical care budget needs in the annual President’s Budget to identify any gaps in the process or data limitations, and develop and implement a plan to strengthen the process.

Establish and implement a plan to review current processes and procedures for involving program offices and pertinent subject matter experts in developing the Enrollee Health Care Projection Model inputs for specific areas such as community care, staffing, pharmacy services, and prosthetics services, and formalize the expectations of their involvement in this process through guidance or protocols.

Develop and implement an approach to estimate medical care personnel needs and costs to increase the accuracy and reliability of information included in the annual President’s Budget.

Institutionalize a regular cycle of at least quarterly fiscal reviews among assistant under secretaries for health, network directors, and program offices that routinely assess key cost drivers and other areas of concern, such as staffing, community care growth, and local initiatives.

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

The Veterans Integrated Service Network Director, in conjunction with facility directors, reassess community care staffing needs and act as necessary.

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.

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.

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

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.

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 after administratively closing consults that are not low risk.

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.

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.

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.

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 other than basic.

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

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 the patient’s electronic health record when they receive medical documentation from the community provider.

The Montana VA Healthcare System Director assesses the timeliness of appointment setting for direct and community care referrals and ensures facility staff establish appointments within required time frames.

The Montana VA Healthcare System Director assesses the timeliness of completion of community care appointments within 90 days of requested date and acts on identified opportunities for improvement.

The Montana VA Healthcare System Director reviews consult management practices and ensures receiving staff document scheduled appointment dates for VA direct care referrals.

The Montana VA Healthcare System Director reviews appointment wait times and acts on identified opportunities for improvement.

The Montana VA Healthcare System Director ensures community care providers utilized by the system are designated as eligible in the Provider Profile Management System and acts on identified opportunities to improve the accuracy of eligibility designations.

Clarify policies, guidance, and/or training on when admissions holds, removal of veterans from grantee facilities, and the withholding or suspension of per diem payments are appropriate and required.

Clarify policies, guidance, and/or training on how facility staff determine whether corrective actions for an identified problem related to a grantee should be required or suggested, including what factors to consider, who makes the final determination, and whether and how the determination is reviewed by others.

Implement a mechanism designed to reasonably ensure that VA oversight staff take appropriate enforcement measures to address persistent or recurring deficiencies by a Grant and Per Diem grantee that pose risks to veteran care and safety.

Ensure grant agreements require the grantee to promptly disclose to VA any adverse health or safety conditions occurring at any facility where VA-funded participants are receiving service, including the occurrence of sentinel events affecting non-VA-funded participants on the grantee’s premises and any adverse health or safety inspection results or similar findings made concerning the grantee’s premises or operations by any non-VA oversight entity, such as a federal, state, county, or local regulator.

Ensure Grant and Per Diem participants residing at the Veterans Village of San Diego (VVSD) who are eligible for clinical drug treatment receive appropriate support to obtain those services despite the closure of VVSD’s clinical treatment housing model.

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.

Ensure the Office of Integrated Veteran Care improves oversight of healthcare claim payments to prevent, identify, and recover overpayments in a more timely manner.

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.

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.

Make certain the Office of Procurement, Acquisition, and Logistics develops sufficient oversight and internal controls over the contract modification process to prevent program overpayments.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

The New York/New Jersey VA Health Care Network Director conducts a review of system leaders’ responses to repeated concerns regarding delayed community care consult scheduling for patients with serious health conditions to determine whether leaders’ actions were in alignment with patient safety and high reliability organizational principles, and take action as warranted.

The New York/New Jersey VA Health Care Network Director ensures VA Western New York Health Care System Director develops community care consult practices and procedures for managing consults deemed high-risk or complex, implements an effective process to ensure consistency with processing consults within Veterans Health Administration timeliness requirements, and audits for compliance.

The VA Western New York Health Care System Director ensures system community care leaders develop and implement standardized operating procedures for consult management consistent with Veterans Health Administration standards, provide training to community care staff, monitor compliance, and evaluate effectiveness.

The VA Western New York Health Care System Director ensures all efforts to conduct an institutional disclosure to Patient A’s family are made and that the disclosure is documented in the patient’s electronic health record, as required.

Request that the contractor perform a self-audit of local VA claims.

Verify that the contractor has completed the process of refunding local VA claims.