All Reports

Consult Delays at the Atlanta VA Health Care System in Decatur, Georgia
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18-01622-207
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Topics:  Appointment Scheduling and Wait Times ● Community Care

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/20/2023
The Atlanta VA Health Care System Director reviews the process for non-VA community care consult performance measurements, evaluates compliance with Veterans Health Administration policy, and implements an action plan as needed.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/20/2023
The Atlanta VA Health Care System Director ensures managers review the backlog of open non-VA community care consults and implements an action plan as needed.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/16/2021
The Atlanta VA Health Care System Director verifies that managers develop a process to analyze and confirm non-VA community care staff compliance with daily monitoring according to Veterans Health Administration policy.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2021
The Atlanta VA Health Care System Director evaluates the process for the hiring, training, and supervision of non-VA community care staff, and implements an action plan as needed.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2021
The Atlanta VA Health Care System Director ensures that managers review the patient cases referred to the Atlanta VA Health Care System by the Office of Inspector General, assesses these patients for adverse clinical outcomes, and implements action plans as needed.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/18/2021
The Atlanta VA Health Care System Director makes certain that managers develop a policy to identify non-VA Community Care consults that are administratively closed but do not have relevant medical documentation, and implements an action plan as needed to be in alignment with Veterans Health Administration policy.
Review of Highly Rural Community-Based Outpatient Clinics' Limited Access to Select Specialty Care
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19-00017-191
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Topics:  Community Care

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/7/2021
The Under Secretary for Health completes a specialty care needs assessment for highly rural community-based outpatient clinics to include internet bandwidth and telehealth equipment and develops options for the delivery of safe patient care.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2021
The Under Secretary for Health ensures that the Veterans Health Administration Site Tracking system validation process is completed by each Veterans Integrated Service Network as required and monitors for compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2021
The Under Secretary for Health ensures that facilities and Veterans Integrated Service Networks maintain accurate and current information on websites as required and monitors for compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/13/2021
The Under Secretary for Health completes an assessment to determine whether highly rural community-based outpatient clinics that are located in a non-VA community hospital or health care center are fully utilizing the resources available at the non-VA facilities and takes action as indicated.
Overtime Use in the Office of Community Care to Process Non-VA Care Claims Not Effectively Monitored
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18-06292-117
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Topics:  Community Care

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/23/2020
The Office of Community Care completes a review of the OIG identified employees who had no claims processing production or activity in the Fee Basis Claims System during overtime hours to determine whether the employees’ conduct requires disciplinary or other corrective action, as appropriate.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2021
The Office of Community Care establishes and implements controls for Payment Operations and Management supervisors to effectively monitor and assess staff productivity during overtime hours to mitigate the risk of overtime abuse.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/23/2020
The Payment Operations and Management directorate clarifies and communicates nurse productivity standards and requirements.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/23/2020
The Payment Operations and Management directorate develops and implements formal guidance for its staff on the appropriate use of overtime, and the controls needed for monitoring compliance.
Review of Access to Care and Capabilities during VA’s Transition to a New Electronic Health Record System at the Mann-Grandstaff VA Medical Center in Spokane, Washington
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19-09447-136
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Topics:  Electronic Health Records Modernization (EHRM) ● Community Care

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/12/2025

The Under Secretary for Health, in conjunction with the Office of Electronic Health Records Modernization, evaluates the impact of the new electronic health record implementation on productivity and provides operational guidance and required resources to facilities prior to go-live.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/8/2022
The Under Secretary for Health, in conjunction with the Office of Electronic Health Records Modernization, identifies the impact of the mitigation strategies on user and patient experience at go-live and takes action, as needed.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/13/2021
The Executive Director, Office of Electronic Health Records Modernization, in conjunction with the Under Secretary for Health, ensures that clear guidance is given to facility staff on what electronic health record capabilities will be available at go-live.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/12/2025

The Under Secretary for Health, in conjunction with the Office of Electronic Health Records Modernization, reevaluates the electronic health record modernization deployment timeline to minimize the number of required mitigation strategies at go-live.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/13/2021
The Veterans Integrated Service Network Director collaborates with facility leaders to implement VA-provided operational guidance and supports required resources needed throughout the transition to the new electronic health record system.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/16/2020
The Veterans Integrated Service Network Director ensures that positions required for the transition to the new electronic health record system are staffed and trained prior to go-live.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/22/2021
The Mann-Grandstaff VA Medical Center Director ensures that community care consults are managed through go-live to ensure accuracy, completeness, and to avoid the need for manual reentry after go-live.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/22/2021
The Mann-Grandstaff VA Medical Center Director ensures that patients receive medication refills in a timely manner throughout the transition to the new electronic health record system.
Review of Veterans Health Administration Community Living Centers and Corresponding Star Ratings
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18-05113-81
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Topics:  Community Care

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2021
The Under Secretary for Health supplements the use of Community Living Center Compare with adjustment measures to better address the Community Living Center to Centers for Medicare and Medicaid Services comparison challenges for veterans, their families, and the public.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2021
The Under Secretary for Health continues to develop specific measures that employ a more rigorous risk adjustment to better measure staffing and quality performance with respect to the Community Living Center population.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/12/2021
The Under Secretary for Health develops a resource that works in conjunction with other information about Community Living Centers to provide an understandable narrative for veterans, their families, and the public.
Deficiencies in the Women Veterans Health Program and Other Quality Management Concerns at the North Texas VA Healthcare System
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19-06378-73
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Topics:  Patient Safety ● Community Care

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2020
The VA North Texas Health Care System Director takes steps to ensure sufficient staffing to provide gender-specific care by designated women’s health primary care providers.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2020
The VA North Texas Health Care System Director ensures steps are taken to reduce panel sizes of designated women’s health primary care providers as required by Veterans Health Administration policy.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/20/2020
The VA North Texas Health Care System Director reviews the Veterans Health Administration policy recommended extended appointment times for comprehensive women veterans healthcare examinations and takes action as appropriate to achieve compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2020
The VA North Texas Health Care System Director takes steps to ensure that appropriate resources, such as equipment, supplies, and space, are adequate to support comprehensive women veterans healthcare.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/1/2021
The VA North Texas Health Care System Director takes steps to ensure that the Women Veterans Program Manager participates in the environment of care rounds and monitors for compliance with Veterans Health Administration policy.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2020
The VA North Texas Health Care System Director evaluates clinic areas where gender specific primary care is currently provided and when planning renovations to existing areas to ensure adequate restroom access for women veterans and takes action as appropriate.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2021
The VA North Texas Health Care System Director continues to evaluate and support staffing changes in the gynecology specialty clinic to enhance services.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/24/2022
The VA North Texas Health Care System Director ensures implementation of an effective tracking mechanism to ensure VA providers receive results for women veterans referred to care in the community and monitors for compliance with Veterans Health Administration policy.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/24/2022
The VA North Texas Health Care System Director verifies review of the electronic health records of women veterans referred to Care in the Community whose medical records have not been obtained and takes action if indicated.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2020
The VA North Texas Health Care System Director takes steps to ensure performance and evaluation processes provide the intended assessment of compliance with Veterans Health Administration requirements and monitors for compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2020
The VA North Texas Health Care System Director verifies that institutional disclosures are conducted for events that meet disclosure criteria and monitors for compliance with Veterans Health Administration policy.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2020
The VA North Texas Health Care System Director takes steps to ensure the required number of combined totals of root cause analyses and aggregated reviews are completed, and monitors for compliance with Veterans Health Administration policy.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2020
The VA North Texas Health Care System Director ensures completion of root cause analyses within the required timeframes and monitors for compliance with Veterans Health Administration policy.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/20/2020
The VA North Texas Health Care System Director verifies that staff complete training on policy related to high-risk patient goals of care conversations for life-sustaining treatment plans and monitors for completion of training.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2021
The VA North Texas Health Care System Director ensures staff conduct high-risk patient goals of care conversations for life-sustaining treatment plans as required and monitors for compliance with Veterans Health Administration policy.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2021
The VA North Texas Health Care System Director takes steps to ensure provider documentation of high-risk patient goals of care and life-sustaining treatment plan in the required electronic health record template and monitors for compliance with Veterans Health Administration policy.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/28/2021
The VA North Texas Health Care System Director verifies capture and reporting of all codes to the resuscitation subcommittee and monitors for compliance with Veterans Health Administration policy.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/28/2021
The VA North Texas Health Care System Director ensures that the Critical Care Committee minutes reflect corrective action plans and follow-through to remediate concerns identified by the resuscitation subcommittee and monitors for compliance.
Improvements Are Needed in the Community Care Consult Process at VISN 8 Facilities
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18-05121-36
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Topics:  Community Care

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/31/2020
Develop and implement a mechanism for VA facilities and their respective VA community care departments to routinely identify and exchange wait time data to help make decisions that reduce patient wait times.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/20/2020
Routinely monitor the timeliness of each distinct stage of the community care consult process so Veterans Integrated Service Network 8 facilities can identify specific delays.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/20/2020
Ensure facilities routinely monitor the Office of Community Care staffing tool and take appropriate actions to confirm actual staffing levels are sufficient to meet workloads in a timely manner.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/12/2020
Ensure community care administrative staff are effectively cross-trained to carry out applicable administrative consult processing duties to streamline scheduling and authorizations, and implement a control to monitor whether facilities are processing community care consults in accordance with Office of Community Care guidance and recommendations.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/13/2021
Develop and implement specific facility plans to address the backlog of open consults and the growing number of new consults.
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