Date Issued
|
Report Number
22-00180-169
All Reports
Date Issued
|
Report Number
21-03080-142
|
Topics: Information Technology and Security
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Information and Technology (OIT)
Closure Date: 10/25/2022
The OIG recommends the Assistant Secretary for Information and Technology develop controls to help ensure minor applications are not misclassified as assets and undergo the appropriate security accreditation and certification process.
No. 2
to Information and Technology (OIT),Veterans Benefits Administration (VBA)
Closure Date: 8/7/2023
The OIG recommends the Assistant Secretary for Information and Technology in conjunction with the Under Secretary for Benefits, make certain that appropriate security and privacy controls are implemented during the development of information technology systems before being hosted on VA’s network.
No. 3
to Information and Technology (OIT),Veterans Benefits Administration (VBA)
The OIG recommends the Under Secretary for Benefits, in conjunction with the Assistant Secretary for Information and Technology, establish a mechanism to gain assurance that proper Office of Information Technology project management processes and protocols are followed when establishing information technology systems and applications.
No. 4
to Veterans Benefits Administration (VBA)
Closure Date: 10/25/2022
The OIG recommends the Under Secretary for Benefits establish policies and procedures to ensure the Mission Accountability Support Tracker is used appropriately and does not contain unnecessary personally identifiable information.
Date Issued
|
Report Number
21-00288-175
|
Topics: Suicide Prevention
● Care Coordination
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 11/15/2022
The Executive Director evaluates and determines reasons for noncompliance and ensures leaders identify adverse events as sentinel events when criteria are met and conduct institutional disclosures as required.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 1/31/2023
The Executive Director evaluates and determines any additional reasons for noncompliance and designates a systems redesign and improvement coordinator.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 1/31/2023
The Executive Director evaluates and determines any additional reasons for noncompliance and makes certain that credentialing staff complete primary source verification of all registered nurses’ licenses prior to initial appointment.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 11/15/2022
The Associate Director, Clinical Services evaluates and determines any additional reasons for noncompliance and ensures staff complete mandatory suicide safety plan training prior to developing suicide safety plans.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 11/15/2022
The Associate Director, Clinical Services and Associate Director, Patient Care Services evaluate and determine reasons for noncompliance and ensure staff monitor and evaluate all inter-facility transfers as part of VHA’s Quality Management Program.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 5/2/2023
The Associate Director, Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures nurse-to-nurse communication occurs between sending and receiving facilities.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 1/31/2023
The Executive Director evaluates and determines any additional reasons for noncompliance and ensures Employee Threat Assessment Team meetings are held and members complete training, as required.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 1/31/2023
The Associate Director, Clinical Services and Associate Director, Patient Care Services evaluate and determine any additional reasons for noncompliance and make certain that required members attend Disruptive Behavior Committee meetings.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 4/4/2024
The Executive Director evaluates and determines any additional reasons for noncompliance and ensures employees complete all required prevention and management of disruptive behavior training based on the risk level assigned to their work areas.
Date Issued
|
Report Number
21-02197-165
|
Topics: Financial Management
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 11/23/2022
Ensure healthcare system finance office staff are made aware of policy requirements for open obligations and the responsible healthcare system finance office conducts reviews on all open obligations as required by VA Financial Policies and Procedures, Volume II, Chapter 5, “Obligations Policy,” October 2020.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 8/6/2023
Establish procedures to ensure cardholders comply with record retention and transaction-processing requirements as stated in VA’s Financial Policy, vol. XVI, “Charge Card Program.”
No. 3
to Veterans Health Administration (VHA)
Closure Date: 3/1/2023
Develop a plan to work with the prime vendor to address having adequate stock to meet orders, reducing the need for the healthcare system to use nonprime vendors.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 11/23/2022
Ensure the healthcare system follows the Medical Surgical Prime Vendor-Next Generation ordering hierarchy and purchases items from the Medical Surgical Prime Vendor-Next Generation contract before using other sources.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 11/23/2022
Ensure the healthcare system elects and is granted a delivery method that meets just-in-time requirements.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 3/1/2023
Ensure the healthcare system submits Medical Surgical Prime Vendor-Next Generation waiver requests and obtains approval before purchasing available formulary items from nonprime vendor sources.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 11/23/2022
Ensure logistics staff and contracting officer’s representatives use all the tools available to inform the Medical Supplies Program Office and Strategic Acquisition Center of prime vendor performance issues.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 11/23/2022
Develop formalized processes for achieving identified efficiency targets and use available pharmacy data to make business decisions.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 11/23/2022
Educate non-VA providers on prescribing lower-cost drugs.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 5/4/2023
Develop and implement a plan to increase inventory turnover to the Veterans Health Administration-recommended level.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 3/1/2023
Develop and implement a plan to complete facility-based inventory audits of noncontrolled drug line items in compliance with Veterans Health Administration policy.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 5/4/2023
Develop a plan to ensure that appropriate metrics for monitoring compliance with Veterans Health Administration policy are calculated correctly in the Pharmacy Benefits Management inventory reporting tool.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 185,533.00
Date Issued
|
Report Number
21-00283-173
|
Topics: Patient Safety
● Care Coordination
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 11/22/2022
The Chief of Staff evaluates and determines additional reasons for noncomplianceand ensures that peer reviewers use at least one of the nine aspects of care forevaluations.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 11/22/2022
The Chief of Staff evaluates and determines any additional reasons fornoncompliance and ensures that the Peer Review Committee recommendsimprovement actions for Level 3 peer reviews.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 11/22/2022
The Chief of Staff evaluates and determines any additional reasons fornoncompliance and makes certain that the Peer Review Committee completes finalpeer reviews within 120 calendar days from the date it is determined a peer reviewis required, or the System Director approves any necessary extensions in writing.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 5/19/2023
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and make certain that staff monitor and evaluate all transfers as part of VHA’s Quality Management Program.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 5/19/2023
The Chief of Staff and Associate Director for Patient Care Services evaluate anddetermine any additional reasons for noncompliance and ensure that transferringproviders complete all elements of the VA Inter-Facility Transfer Form or afacility-defined equivalent note in the electronic health record.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 5/19/2023
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure that transferring providers send patients’ active medication lists to receiving facilities during inter-facility transfers.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 4/29/2024
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that nurse-to-nurse communication occurs between sending and receiving facilities.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 7/10/2024
The System Director evaluates and determines any additional reasons for noncompliance and ensures employees complete all required prevention and management of disruptive behavior training based on the risk level assigned to their work area.
Date Issued
|
Report Number
21-01237-127
|
Topics: Claims and Medical Exams
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 1/24/2023
Assess and modify contracts and any renewals to ensure that vendors can be heldaccountable for unsatisfactory performance by applying monetary disincentives.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 5/5/2023
Assess and modify contracts and any renewals to ensure procedures are established for vendors to correct errors identified by the Medical Disability Examination Office.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 5/5/2023
Implement procedures requiring the Medical Disability Examination Office tocommunicate exam errors to the Office of Field Operations and the regional officesand demonstrate progress in correcting the identified errors.
No. 4
to Veterans Benefits Administration (VBA)
Closure Date: 8/10/2022
Implement procedures requiring the Medical Disability Examination Office toanalyze all available error data and provide systemic exam issues and error trends tovendors.
Date Issued
|
Report Number
20-02186-78
|
Topics: Mental Health
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 7/12/2023
Ensure program officials in collaboration with regional and local leaders address call management system data integrity issues before they use data to assess the management of referrals.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 5/1/2023
Have the program office develop formal training and guidance for coordinators on how to use patient outcome codes and regional and local leaders ensure the training is completed.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 5/1/2023
Ensure regional and local managers regularly review crisis line referral information in the electronic health records to verify coordinators are completing and documenting appropriate follow-up on referrals and the program office performs regular audits, monitors, reports upon, and initiates actions, as needed, to ensure compliance with and completion of referral follow-up.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 7/12/2023
Consider guidance within coordinators’ training tools to clarify the expectations for coordinators to follow up on referred veterans who have been hospitalized in a non-VA hospital, admitted to an emergency department (VA and non-VA), or provided a welfare check.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 5/1/2023
Have regional and local managers monitor coordinators’ call attempts to ensure they are interspersed over a three-day period and provide them with referral closure information to assist in their monitoring.
Date Issued
|
Report Number
21-00286-163
|
Topics: Suicide Prevention
● Care Coordination
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 6/2/2022
The Medical Center Director evaluates and determines any additional reasons fornoncompliance and makes certain that the Surgical Workgroup Committee meets atleast monthly.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 6/2/2022
The Chief of Staff evaluates and determines any additional reasons fornoncompliance and ensures staff complete mandatory suicide safety plan trainingprior to developing suicide safety plans.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 6/2/2022
The Chief of Staff and Associate Director/Patient Care Services evaluate anddetermine any additional reasons for noncompliance and ensure staff send activemedication lists to receiving facilities during inter-facility transfers.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 10/2/2023
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures all staff complete the required prevention and management of disruptive behavior training based on the risk level assigned to their work area.
Date Issued
|
Report Number
21-00293-170
|
Topics: Care Coordination
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 6/2/2022
The Medical Center Director evaluates and determines any additional reasons fornoncompliance and ensures leaders conduct institutional disclosures for all sentinelevents.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 7/12/2023
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the Systems Redesign Coordinator participates on the Quality, Safety & Value Council.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 10/25/2022
The Medical Center Director evaluates and determines any additional reasons fornoncompliance and makes certain that the Facility Surgical Work Group meets atleast monthly.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 10/25/2022
The Medical Center Director evaluates and determines any additional reasons fornoncompliance and ensures that core members consistently attend Facility SurgicalWork Group meetings.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 2/12/2024
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure that the referring physician completes all required elements of the VA Inter-Facility Transfer Form or facility-defined equivalent note.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 11/16/2023
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and make certain that required representatives attend the Disruptive Behavior Committee meetings.
Date Issued
|
Report Number
21-02453-99
|
Topics: Information Technology and Security
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Information and Technology (OIT)
Closure Date: 6/1/2022
Implement more effective inventory management tools for all network segments.
No. 2
to Information and Technology (OIT)
Closure Date: 9/29/2022
Implement a more effective vulnerability and flaw remediation program that can accurately identify vulnerabilities and enforce flaw remediation.
No. 3
to Information and Technology (OIT)
Closure Date: 6/1/2022
Develop and implement methods to ensure delivery, receipt, and understanding of assigned roles and responsibilities for Consolidated Mail Outpatient Pharmacy activities to ensure full implementation of approved policy.
No. 4
to Information and Technology (OIT)
Closure Date: 9/25/2023
Develop and implement a disaster recovery plan and capability that will restore operations in the event of a disruption to critical operations.
No. 5
to Information and Technology (OIT)
Closure Date: 6/1/2022
Task the facility manager to change the default username and password for the security camera system.
No. 6
to Information and Technology (OIT)
Closure Date: 9/29/2022
Request the Office of Information and Technology to configure audit logging on the misconfigured devices in accordance with established baselines, policy, and procedures.
Date Issued
|
Report Number
21-03020-168
|
Topics: Electronic Health Records Modernization (EHRM)
● Patient Safety
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 3/28/2024
The Deputy Secretary completes an evaluation of gaps in new electronic health record metrics and takes action as warranted.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 7/9/2024
The Deputy Secretary completes an evaluation of factors affecting the availability of metrics and takes action as warranted.
Date Issued
|
Report Number
21-01123-97
|
Topics: Information Technology and Security
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Information and Technology (OIT)
Closure Date: 8/7/2023
The assistant secretary for information and technology and chief information officer will ensure the Veterans Data Integration and Federation Enterprise Platform security objectives are all set at a categorization level of high based upon both the sensitive personal information maintained in the system and the approved risk assessment.
No. 2
to Information and Technology (OIT)
Closure Date: 8/7/2023
The assistant secretary for information and technology and chief information officer will act to reestablish the Veterans Data Integration and Federation Enterprise Platform in the Enterprise Mission Assurance Support Service to ensure appropriate security controls are implemented and the system is assessed at the high risk level.
No. 3
to Information and Technology (OIT)
Closure Date: 1/4/2023
The assistant secretary for information and technology and chief information officer will ensure the Office of Information Technology provides appropriate oversight and follows proper program management processes and protocols when establishing and monitoring security controls for IT systems.
Date Issued
|
Report Number
21-03305-139
|
Topics: Information Technology and Security
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Information and Technology (OIT)
Closure Date: 10/20/2022
Implement an effective inventory management system for all network segments.
No. 2
to Information and Technology (OIT)
Closure Date: 3/23/2023
Implement an effective vulnerability and flaw remediation program that can
accurately identify vulnerabilities and enforce flaw remediation
No. 3
to Information and Technology (OIT)
Closure Date: 6/1/2022
Develop and implement methods to ensure delivery, receipt, and understanding of assigned roles and responsibilities for local activities to ensure full implementation
of approved policy.
No. 4
to Information and Technology (OIT)
Closure Date: 6/1/2022
Implement effective configuration control processes that ensure network devices maintain standards mandated by the VA Office of Information and Technology Configuration Control Board.
No. 5
to Information and Technology (OIT)
Closure Date: 1/14/2025
Remove or disable group accounts to comply with established requirements and criteria.
No. 6
to Information and Technology (OIT)
Closure Date: 6/1/2022
Ensure employees lock devices when they are unattended.
No. 7
to Information and Technology (OIT)
Closure Date: 6/1/2022
Implement database authentication processes that comply with National Institute of
Standards and Technology standards and VA security requirements.
No. 8
to Information and Technology (OIT)
Closure Date: 10/20/2022
Implement a process to retain database logs for a period consistent with VA’s record
retention policy.
No. 9
to Information and Technology (OIT)
Closure Date: 6/1/2022
Establish a process for validating and logging the sanitization of hard drives.
No. 10
to Information and Technology (OIT)
Closure Date: 10/20/2022
Implement parking barriers that meet VA Physical Security & Resiliency Design Manual
requirements.
Date Issued
|
Report Number
21-00240-158
|
Topics: Medical Staff Privileging Credentialing
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 1/17/2023
The Chief Medical Officer evaluates and determines additional reasons for noncompliance and makes certain to review the credentials file and approve the VA appointment for physicians who had a potentially disqualifying licensure action.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 1/17/2023
The Network Director evaluates and determines any additional reasons for noncompliance and ensures that the Emergency Management Committee conducts annual reviews of the Emergency and Continuity of Operations Plans; Hazards Vulnerability Analysis; and Veterans Integrated Service Network-wide strengths, weaknesses, priorities, and requirements for improvement, and submits the reviews to executive leaders for approval.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 10/18/2022
The Network Director evaluates and determines any additional reasons for noncompliance and appoints a permanent Veterans Integrated Service Network lead women veterans program manager.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 1/17/2023
The Network Director evaluates and determines any additional reasons for noncompliance and makes certain that a lead women veterans program manager conducts yearly visits at each facility in the Veterans Integrated Service Network.
Date Issued
|
Report Number
20-04443-167
|
Topics: Patient Safety
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 10/13/2022
The VA Sunshine Healthcare Network Director ensures a review of the patient incident is conducted to determine whether further administrative action or reporting to state licensing board(s), or both, is warranted for facility staff involved in the incident, and takes action as appropriate.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 10/13/2022
The Malcom Randall VA Medical Center Director ensures that Emergency Department nurses and Administrative Officers of the Day prioritize patient care before patient eligibility status when patients present with an emergency medical condition, holds staff accountable when violations occur, and monitors for ongoing compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 10/13/2022
The Malcom Randall VA Medical Center Director ensures that Emergency Department nurse competencies are current, complete, and validated as required, and monitors for ongoing compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 10/13/2022
The Malcom Randall VA Medical Center Director conducts an internal review of the Emergency Department Nurse Educator’s replication of the 2019 Ongoing Competency Assessments and attestation of competency completion to determine whether administrative action is warranted and takes action as appropriate.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 10/13/2022
The Malcom Randall VA Medical Center Director evaluates the status of action plans referenced in this report and monitors the implementation and efficacy of action items to closure.
Date Issued
|
Report Number
21-00299-162
|
Topics: Suicide Prevention
● Care Coordination
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 1/17/2023
The System Director evaluates and determines any additional reasons for noncompliance and ensures that leaders identify adverse events as sentinel events when criteria are met.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 1/17/2023
The System Director evaluates and determines any additional reasons for noncompliance and ensures that leaders conduct institutional disclosures for all sentinel events.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 1/17/2023
The System Director evaluates and determines any additional reasons for noncompliance and makes certain that staff complete final peer reviews within 120 calendar days or approves a written extension request.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 1/17/2023
The Executive Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that staff complete mandatory suicide safety plan training prior to developing suicide safety plans.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 1/4/2024
The Executive Chief of Staff and Associate Director, Patient Services evaluate and determine any additional reasons for noncompliance and ensure that appropriately privileged providers complete all elements of the VA Inter-Facility Transfer Form or a facility-defined equivalent note in the electronic health record prior to patient transfers.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 1/17/2023
The Executive Chief of Staff and Associate Director, Patient Services evaluate and determine any additional reasons for noncompliance and ensure all required members attend Disruptive Behavior Committee meetings.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 1/17/2023
The Executive Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain the Disruptive Behavior Committee documents decisions to implement Orders of Behavioral Restriction and patients’ notification of the orders in the Disruptive Behavior Reporting System.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 6/3/2024
The System Director evaluates and determines any additional reasons for noncompliance and ensures staff complete all required Prevention and Management of Disruptive Behavior training based on the risk level assigned to their work areas.
Date Issued
|
Report Number
21-00295-161
|
Topics: Care Coordination
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 1/17/2023
The Executive Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that the Chief of Staff attends Facility Surgical Work Group meetings.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 1/17/2023
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that the Facility Surgical Work Group reviews National Surgery Office surgical quality reports.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 11/2/2022
The Executive Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that a written policy is in place to ensure the safe, appropriate, orderly, and timely transfer of patients.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 1/17/2023
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and make certain that staff monitor and evaluate all transfers as part of VHA’s Quality Management Program.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 1/17/2023
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that transferring providers complete the VA Inter-Facility Transfer Form or a facility-defined equivalent note to include required elements in the electronic health record prior to patient transfers.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 1/17/2023
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that transferring providers send patients’ active medication lists to receiving facilities during inter-facility transfers.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 1/17/2023
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that nurse-to-nurse communication occurs between the sending and receiving facility.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 4/20/2023
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure the Prevention and Management of Disruptive Behavior Program representative attends Disruptive Behavior Committee meetings.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 11/2/2022
The Executive Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that the annual Workplace Behavioral Risk Assessment includes participation by VA police and a patient safety representative.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 2/6/2024
The Executive Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that staff complete all required prevention and management of disruptive behavior training based on the risk level assigned to their work areas.
Date Issued
|
Report Number
21-00846-104
|
Topics: Community Care
● Financial Management
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 2/10/2025
Maximize opportunities to bill veterans’ private health insurers for recoverable claims by developing procedures that align and prioritize the processing of such claims to insurers’ filing deadlines.
No. 2
to Veterans Health Administration (VHA)
Strengthen information system controls to make certain that complete and accurate claims information is transferred between applicable current and future Community Care payment systems and the Consolidated Patient Account Centers’ workflow tool and VistA patient treatment files.
No. 3
to Veterans Health Administration (VHA)
Conduct an assessment to determine if staffing resources and workload are sufficiently aligned to process the anticipated volume of claims to be billed to veterans’ private health insurers and make adjustments as needed.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 805,200,000.00
Date Issued
|
Report Number
21-01820-159
|
Topics: Community Care
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 4/3/2023
The VISN 23 Director ensures implementation and sustainment of initial and annual home visits for patients accepted into the VISN 23 home dialysis program.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 9/28/2023
The VISN 23 Director ensures the implementation and sustainment of quality monitoring of contracted clinical services for home dialysis.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 7/11/2023
The VISN 23 Director ensures that VA providers receive mammography reports from non-VA providers within the established acceptable timeframe.