Date Issued
|
Report Number
21-01052-33
|
Topics: Financial Management
All Reports
Date Issued
|
Report Number
21-00434-233
|
Topics: Appointment Scheduling and Wait Times
● Electronic Health Records Modernization (EHRM)
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Electronic Health Record Modernization Integration Office (EHRM IO),Veterans Health Administration (VHA)
Closure Date: 12/21/2022
Continue to make improvements to the scheduling training as needed to address feedback from schedulers.
No. 2
to Electronic Health Record Modernization Integration Office (EHRM IO),Veterans Health Administration (VHA)
Closure Date: 6/22/2023
Require that some schedulers from each clinic fully test the scheduling capabilities of their clinics, solicit feedback from the schedulers to identify system or process issues, and make improvements as needed
No. 3
to Veterans Health Administration (VHA)
Closure Date: 1/2/2024
Issue guidance to facility staff on which date fields in the new system schedulers should use to measure patient wait times.
No. 4
to Electronic Health Record Modernization Integration Office (EHRM IO),Veterans Health Administration (VHA)
Closure Date: 10/27/2022
Develop a mechanism to track and then monitor all tickets related to the new scheduling system, and then ensure the Office of Electronic Health Record Modernization evaluates whether Cerner effectively resolved the tickets within the timeliness metrics established in the contract.
No. 5
to Electronic Health Record Modernization Integration Office (EHRM IO),Veterans Health Administration (VHA)
Closure Date: 10/27/2022
Develop a strategy to identify and resolve additional scheduling issues in a timely manner as the Office of Electronic Health Record Modernization deploys the new electronic health record at future facilities.
No. 6
to Electronic Health Record Modernization Integration Office (EHRM IO),Veterans Health Administration (VHA)
Closure Date: 7/14/2023
Develop a mechanism to assess whether facility employees accurately scheduled patient appointments in the new scheduling system, and then ensure facility leaders conduct routine scheduling audits.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 3/13/2024
Evaluate whether patients received care within the time frames directed by Veterans Health Administration policy when scheduled through the new system.
No. 8
to Electronic Health Record Modernization Integration Office (EHRM IO)
Closure Date: 10/27/2022
Provide guidance to schedulers to consistently address system limitations until problems are resolved.
Date Issued
|
Report Number
20-01324-215
|
Topics: System Development and Implementation
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 1/17/2023
Director of the Office of Acquisitions, Logistics, and Construction: Ensure the VA Logistics Redesign office revisits its Defense Medical Logistics Standard Support system oversight and deployment processes to align them with VA’s acquisition program management framework requirements.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 1/17/2023
Director of the Office of Acquisitions, Logistics, and Construction: Develop processes to better identify unmet high-priority business requirements and post-deployment challenges at the Captain James A. Lovell Health Care Center and future sites and to make certain that solutions are developed and implemented.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 1/17/2023
Director of the Office of Acquisitions, Logistics, and Construction: Properly staff the VA Logistics Redesign office with personnel who possess the appropriate subject matter expertise and employ measures to improve continuity in the project management team that oversees the Defense Medical Logistics Standard Support system’s implementation.
Date Issued
|
Report Number
20-03437-26
|
Topics: COVID-19
● Community Care
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 3/30/2023
The Under Secretary for Health evaluates community care resources, facility practices, and Veterans Health Administration requirements related to stat community care consult processes and takes action as warranted to ensure that patients receive clinically indicated care in the appropriate time frame
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/30/2023
The Under Secretary for Health clarifies guidance to VA medical facilities for stat community care consults including the timeliness of clinical review and approval, retrieval of medical records, and administrative closure.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 3/30/2023
The Under Secretary for Health issues guidance to VA medical facilities regarding the override process for stat community care consults to include collaboration expected between the referring provider and the designee.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 3/30/2023
The Under Secretary for Health evaluates patient involvement in decision-making regarding clinical reviewers’ modification of the urgency status of stat community care consults to determine if the process is in alignment with Veterans Health Administration patient-centered care goals and takes action as warranted.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 12/12/2023
The Under Secretary for Health evaluates the time frame for adjudicating and communicating clinical appeals, determines applicability to the 24-hour requirement for completing stat community care consults, and takes action as warranted.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 4/12/2022
The Under Secretary for Health evaluates adverse event reporting processes in community care, including a review of guidance provided in the VHA National Patient Safety Improvement Handbook, 1050.01 and the VHA Patient Safety Events in Community Care: Reporting, Investigation and Improvement Guidebook for inconsistencies and takes action as warranted.
Date Issued
|
Report Number
20-02908-21
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 1/4/2023
The Executive Director of the Office of Construction and Facilities Management determines whether conducting special reviews should be conducted by the Quality Assurance Service, and if so, establishes policy or procedures to govern this type of work, including standardized processes for communicating and tracking the implementation of recommendations.
Date Issued
|
Report Number
21-01682-25
|
Topics: Mental Health
● Care Coordination
● Patient Safety
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 4/3/2023
The Southern Oregon Rehabilitation Center and Clinics Director conducts an assessment to ensure all applicable elements of the Southern Oregon Rehabilitation Center and Clinics continuing care plan template are addressed when discharging residents from the Mental Health Residential Rehabilitation Treatment Program and takes action as warranted.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 2/17/2023
The Southern Oregon Rehabilitation Center and Clinics Director ensures discharges of residents from the Mental Health Residential Rehabilitation Treatment Program occur during regular business hours in accordance with Veterans Health Administration Directive 1162.02.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 9/27/2022
The Southern Oregon Rehabilitation Center and Clinics Director reviews Southern Oregon Rehabilitation Center and Clinics transportation policies to ensure alignment with Veterans
Health Administration transportation directives, including management of the transport of residents with behavioral flags.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 1/6/2023
The Southern Oregon Rehabilitation Center and Clinics Director develops a process to ensure an updated medical evaluation is conducted should the admission team be notified of a change in
medical status that occurs after a veteran’s initial admission screening medical evaluation but prior to admission to the Mental Health Residential Treatment Program.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 9/27/2022
The Southern Oregon Rehabilitation Center and Clinics Director completes a systematic review of residents’ falls in the shower area on the Mental Health Rehabilitation Residential Program units and takes action as warranted.
Date Issued
|
Report Number
20-04237-09
|
Topics: Financial Management
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Office of Management (OM)
Continue the system modernization efforts that provide VA with the capability to generate the required DATA Act reporting files containing the necessary elements to meet compliance with the DATA Act. Ensure the modernization will provide the following:
a. Accurate reporting of object class, program activity codes, program activity names, and all other elements required by the DATA Act.
b. Award identification to allow VA to be able to develop a File C and reconcile the File C to both summary level data (Files A and B) and award level data (File D).
c. Reconciliations with subsidiary systems.
d. A mechanism to ensure transactions are reported that currently may be excluded due to the use of 1358s.
e. Standardized data fields to allow management to record an award ID across financial and supporting systems.
f. Subsidiary systems that are consistent with USSGL or adequately mapped to USSGL to ensure transactions contain the necessary data elements/field required to meet DATA Act reporting.
g. Differentiation between direct and reimbursable amounts.
No. 2
to Office of Management (OM)
Closure Date: 9/29/2022
Implement a grants management solution across all of VA’s grant programs and develop processes to ensure integration with the new reporting system.
No. 3
to Office of Management (OM)
Improve researching of all root causes of differences between the VBA source systems and the monthly GTAS balances as part of their File B reconciliations. Also, differences should be accumulated and assessed at an aggregate level. The total differences either allocated to programs, reclassified out of other programs, or attributed to MinX JVs should be researched and reported as part of the SAO sub-certification process.
No. 4
to Office of Management (OM)
Continue mapping efforts and ensure programs without entitlement codes are recorded with the correct program activity codes and names rather than defaulting to Compensation.
No. 5
to Office of Management (OM)
Closure Date: 9/29/2022
Work with component level SAO’s to ensure timely receipt of signed certifications.
No. 6
to Office of Management (OM)
Closure Date: 4/28/2023
Include more information in the SAO certifications, the Data Quality Plan document and the data submission about the costing and aggregation methodologies VA uses to report VHA data to increase transparency.
No. 7
to Office of Management (OM)
Closure Date: 4/28/2023
Implement internal controls and update policies and procedures to improve the accuracy of and completeness of the information submitted for DATA Act reporting. The internal controls should ensure the following:
a. Excluded payments not reported due to zip code issues are researched, cleared, and reported in VBA’s life insurance FABS submission.
b. The default code “90” for Congressional District is not used when the county or zip code are unknown; instead, perform research to obtain the required data.
c. Guidance from OMB and Treasury is requested on the proper reporting of the face amount of insurance policies in VBA’s FABS submissions.
d. Management’s policies and procedures (e.g., Standard Operating Procedures) and narratives are updated on a timely basis in coordination with the VA PMO for the most current DATA Act submission procedures and reporting requirements.
No. 8
to Office of Management (OM)
Closure Date: 1/19/2023
Ensure that reconciliations are complete, reconciling items are identified and researched, and any resolutions are clearly documented.
No. 9
to Office of Management (OM)
Investigate potential controls or processes that could identify 1358s that should be reported until the system modernization can implement a solution.
No. 10
to Office of Management (OM)
Closure Date: 1/19/2023
Implement internal controls and update policies and procedures to improve the accuracy of and completeness of the information submitted for FABS reporting. The update should include and adhere to all FABS and DAIMS reporting requirements.
No. 11
to Office of Management (OM)
Closure Date: 5/9/2024
Improve reviewing and validating eCMS actions to underlying contract documentation to assess the completeness and accuracy of data stored in eCMS. Identified exceptions should continue to be documented, and appropriate corrective actions (e.g., adequate training and guidance) should be completed to ensure and improve completeness and accuracy of data stored in eCMS.
No. 12
to Office of Management (OM)
Closure Date: 1/19/2023
Coordinate and report system errors to Treasury on an as needed basis to ensure all required or derivable data elements are reported for FABS submission.
Date Issued
|
Report Number
21-02447-05
|
Topics: Claims and Appeals
Date Issued
|
Report Number
21-00275-11
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 7/13/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures that the Chief of Staff regularly attends Facility Surgical Workgroup meetings.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 4/27/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures that credentialing staff complete primary source verification of all registered nurses’ licenses prior to initial appointment.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 4/7/2022
The Chief of Staff and Associate Director for Patient Care Services evaluate and
determine any additional reasons for noncompliance and ensure all required
representatives attend Disruptive Behavior Committee meetings.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 12/21/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures that staff complete the required prevention and management of disruptive behavior training based on the risk level assigned to their
work areas.
Date Issued
|
Report Number
20-03898-236
|
Topics: Claims and Fiduciary
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 6/3/2022
The OIG recommended the under secretary for benefits update the Veterans Benefits Administration’s adjudication procedures manual section related to notices of proposed adverse action to ensure automated notices align with the Veterans Affairs regulation, which requires material facts and detailed reasons for the proposed decision.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 6/3/2022
The OIG recommended the under secretary for benefits amend the language of the automated notices of proposed adverse action to include all material facts and detailed reasons for the proposed decision.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 3/1/2023
The OIG recommended the under secretary for benefits review all automatically completed fiscal year 2020 pension reductions based on Social Security cost of living adjustments to ensure regulations and procedures were followed, including consideration of supplementary medical insurance premiums and all evidence submitted by the beneficiary.
Date Issued
|
Report Number
21-00270-04
|
Topics: Care Coordination
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 6/23/2022
The Director evaluates and determines any additional reasons for noncompliance and ensures staff conduct institutional disclosures for all applicable sentinel events.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 6/23/2022
The Director evaluates and determines any additional reasons for noncompliance and ensures root cause analyses have actions and associated outcome measures.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 6/23/2022
The Director evaluates and determines any additional reasons for noncompliance and makes certain that core members regularly attend the Surgical Workgroup meetings.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 6/23/2022
The Director evaluates and determines any additional reasons for noncompliance and ensures that credentialing staff complete primary source verification of all registered nurses’ licenses prior to initial appointment.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 2/16/2023
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure that transferring physicians or the assigned designees send active medication lists to the receiving facilities during inter-facility transfers.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 10/4/2022
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. 7
to Veterans Health Administration (VHA)
Closure Date: 1/2/2024
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure all required members attend Disruptive Behavior Committee meetings.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 6/23/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain the Disruptive Behavior Committee documents patient notification of Orders of Behavioral Restriction in the Disruptive Behavior Reporting System.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 6/23/2022
The Director evaluates and determines any additional reasons for noncompliance and ensures the required interdisciplinary team conducts a Workplace Behavioral Risk Assessment each fiscal year.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 9/25/2025
The Director evaluates and determines any additional reasons for noncompliance and ensures that staff complete the required prevention and management of disruptive behavior training based on the risk level assigned to their work areas.
Date Issued
|
Report Number
19-06004-225
|
Topics: Maintenance and Construction
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 4/21/2022
The director of the VA Sierra Pacific Network (VISN 21) should ensure out-of-cycle projects conform to NRM policy urgent-need criteria before approving projects.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 4/21/2022
The director of VISN 21 should study the feasibility of using non-engineering staff to oversee NRM contracts, contracting out for project requirements to free up VISN engineering resources, and sharing engineering resources between VISN 21 facilities.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 1/10/2023
The under secretary for health should implement an engineering staffing model for medical facilities that supports the achievement of VA strategic goals.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 1/10/2023
The under secretary for health should perform annual reviews of the engineering staffing model to determine if adjustments are needed to achieve VA strategic goals.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 9/12/2022
The under secretary for health should ensure medical facilities design long-range action plans that are feasible based on expected NRM budget levels.
No. 6
to Asset Enterprise Management (OAEM)
Closure Date: 4/21/2022
The executive director of the Office of Asset Enterprise Management, in coordination with the under secretary for health, should enforce NRM policy’s urgent-need criteria on out-of-cycle NRM project approvals.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 5/17/2024
The under secretary for health in coordination with the executive director of the Office of Asset Enterprise Management should create a standardized set of performance measures and reporting standards for offices involved in developing, approving, and executing long-range action plans to ensure NRM projects that align with strategic goals are executed.
Date Issued
|
Report Number
21-00274-289
|
Topics: Patient Safety
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 3/3/2022
The Director evaluates and determines additional reasons for noncompliance and ensures the Surgical Workgroup conducts a monthly review of surgical deaths.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/29/2022
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure all required members participate in disruptive behavior event reviews.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 3/29/2022
The Director evaluates and determines any additional reasons for noncompliance and ensures that staff complete the required prevention and management of disruptive behavior training.
Date Issued
|
Report Number
21-00267-290
|
Topics: Suicide Prevention
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 2/28/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures disclosure of adverse events that require an institutional disclosure.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 2/28/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures that the Surgical Work Group reviews surgical deaths monthly.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 7/7/2022
The 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 prevention safety plans.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 9/21/2022
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure all required members attend Disruptive Behavior Committee meetings.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 9/21/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures patient notification of Orders of Behavioral Restriction in the Disruptive Behavior Reporting System include information regarding patients’ right to appeal the orders and the appeals process.
Date Issued
|
Report Number
20-02014-270
|
Topics: Suicide Prevention
Related Media: Video
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 4/4/2022
The District Director determines reasons clinical and administrative quality reviews were not completed and monitors compliance.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 5/26/2022
The District Director evaluates the clinical and administrative quality review report approval process to determine if a timeliness measure is needed and takes action as indicated.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 5/26/2022
The District Director determines reasons clinical and administrative quality review remediation plans were not completed, ensures completion, and monitors compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 5/26/2022
The District Director evaluates the process for resolution of clinical and administrative quality review deficiencies and takes action as necessary.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 8/25/2022
The District Director determines reasons for noncompliance with critical incident quality review (currently known as morbidity and mortality review) of a death by suicide, ensures completion includes an evaluation of vet center services to determine if actions are needed to improve the effectiveness of vet center suicide prevention activities, and monitors compliance.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 10/20/2022
The District Director determines reasons for noncompliance with critical incident quality reviews (currently known as morbidity and mortality reviews) for serious suicide attempts, ensures completion, and monitors compliance.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 8/25/2022
The District Director ensures intake assessments are completed and monitors compliance across all zone vet centers.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 8/25/2022
The District Director ensures military histories are completed and monitors compliance across all zone vet centers.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 2/1/2023
The District Director ensures lethality risk assessments are completed and monitors compliance across all zone vet centers.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 5/26/2022
The District Director, in collaboration with Readjustment Counseling Service Central Office, evaluates the limitations of current tools and tracking methods including reasons completion dates are unavailable in RCSnet and ensures compliance with standards for timely completion of intake assessments and military histories.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 4/4/2022
The District Director determines reasons the Clearwater Vet Center did not have nontraditional hours as required and ensures compliance.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 4/4/2022
The District Director, in collaboration with the support VA medical facility clinical or administrative liaisons, determines the reasons for noncompliance with the Clearwater, Ocala, Ponce, and Sarasota Vet Centers staff participation on mental health councils, and takes action as indicated to ensure compliance with Readjustment Counseling Service requirements.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 4/4/2022
The Under Secretary for Health ensures that the Chief Officer collaborates with the Office of Mental Health and Suicide Prevention to determine reasons for noncompliance with vet centers’ receipt of the monthly Office of Mental Health and Suicide Prevention list of clients with an increased predictive risk for suicide, ensures coordination of care with VA medical facilities for vet center clients on the list, and monitors compliance.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 4/4/2022
The Under Secretary for Health ensures that the Chief Officer collaborates with the Office of Mental Health and Suicide Prevention to determine the reasons updated lists of clients designated as high risk for suicide were not consistently received by vet centers, and ensures a process for vet centers’ receipt of the list in accordance with the Office of Mental Health and Suicide Prevention and Readjustment Counseling Service Memorandum of Understanding.
No. 15
to Veterans Health Administration (VHA)
Closure Date: 5/26/2022
The Under Secretary for Health ensures that the Chief Officer collaborates with the Office of Mental Health and Suicide Prevention to determine reasons for noncompliance with a standardized communication and collaboration process between suicide prevention coordinators and vet centers in accordance with the Office of Mental Health and Suicide Prevention and Readjustment Counseling Service Memorandum of Understanding, and initiates action as necessary.
No. 16
to Veterans Health Administration (VHA)
Closure Date: 4/4/2022
The District Director determines reasons for noncompliance with high risk for suicide flag SharePoint site requirements and the tracking of continuity of care for clients with a high risk suicide flag at the Sarasota Vet Center, takes action to ensure requirement is met, and monitors compliance.
No. 17
to Veterans Health Administration (VHA)
Closure Date: 9/28/2022
The District Director determines reasons for noncompliance with processes for completing and tracking four hours of external clinical consultation per month at the Clearwater, Ocala, Ponce, and Sarasota Vet Centers, ensures that vet center directors implement processes, and monitors compliance.
No. 18
to Veterans Health Administration (VHA)
Closure Date: 4/4/2022
The District Director determines reasons for noncompliance with staff supervision provided by vet center directors at the Clearwater, Ocala, Ponce, and Sarasota Vet Centers, ensures staff supervision occurs as required, and monitors compliance.
No. 19
to Veterans Health Administration (VHA)
Closure Date: 9/28/2022
The District Director verifies and determines reasons for noncompliance with monthly RCSnet chart audits at the Clearwater, Ocala, Ponce, and Sarasota Vet Centers, ensures chart audits are completed as required, and monitors compliance.
No. 20
to Veterans Health Administration (VHA)
Closure Date: 5/26/2022
The District Director determines reasons for errors in training assignments and why completed trainings are not being recorded for employees at the Clearwater, Ocala, Ponce, and Sarasota Vet Centers, ensures all staff complete mandatory trainings as required, and monitors compliance.
No. 21
to Veterans Health Administration (VHA)
Closure Date: 4/4/2022
The District Director evaluates and determines reasons for noncompliance with tactile (braille) signage at the Clearwater, Ocala, Ponce, and Sarasota Vet Centers and ensures all exit doors are compliant with the Architectural Barriers Act.
No. 22
to Veterans Health Administration (VHA)
Closure Date: 4/4/2022
The District Director reviews reasons for noncompliance with securing confidential and sensitive information at the Clearwater and Sarasota Vet Centers and ensures all vet center employees safely and securely store protected health information.
Date Issued
|
Report Number
20-04051-287
|
Topics: Suicide Prevention
Related Media: Video
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 5/24/2022
The District Director determines reasons administrative quality reviews were not completed, ensures completion, and monitors compliance.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/25/2022
The District Director evaluates the administrative quality review report approval process to determine if a timeliness measure is needed and takes actions as indicated.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 9/14/2022
The District Director determines reasons administrative quality review remediation plans did not include documentation of deficiency resolution and the time frame of resolution, takes indicated actions to ensure completion, and monitors compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 5/24/2022
The District Director determines reasons why critical incident quality reviews (currently known as morbidity and mortality reviews) for serious suicide attempts were not completed, ensures completion, and monitors compliance.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 5/24/2022
The District Director determines reasons for non-participation with the root cause analysis investigation for shared clients with the support Veterans Affairs medical facility and establishes processes to ensure required vet center participation.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 9/14/2022
The District Director ensures the intake portion of the psychosocial assessment is completed and monitors compliance across all zone vet centers.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 5/11/2023
The District Director ensures lethality risk assessments are completed and monitors compliance across all zone vet centers.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 5/24/2022
The District Director, in collaboration with Readjustment Counseling Service Central Office, evaluates the limitations of current tools and tracking methods including why completion dates are not available in RCSnet and ensures compliance with standards for timely completion of intake assessments, military histories, and lethality risk assessments.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 9/14/2022
The District Director ensures clinical staff consult and coordinate care with the support VA medical facility for shared clients flagged as high risk for suicide and monitors compliance across all zone vet centers.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 3/25/2022
The District Director ensures clinical staff follow confidentiality requirements when consulting and coordinating care with the support VA medical facility for shared clients flagged as high risk for suicide and monitors compliance across all zone vet centers.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 5/24/2022
The District Director ensures clinical staff consult with the vet center director, external clinical consultant, or VA suicide prevention coordinator following a client’s lethality status change as required and monitors compliance across all zone vet centers.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 12/21/2022
The District Director ensures clinical staff complete crisis reports as required and monitors compliance across all zone vet centers.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 3/25/2022
The District Director, in collaboration with the support VA medical facility clinical or administrative liaisons, determines the reasons for noncompliance with staff participation on mental health councils at Alexandria, Houston Southwest, Laredo, and Mesquite Vet Centers and takes actions as indicated to ensure compliance with Readjustment Counseling Service requirements.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 3/25/2022
The District Director determines reasons a process for completing and tracking four hours of external clinical consultation per month did not occur at the Alexandria, Houston Southwest, Laredo, and Mesquite Vet Centers, ensures vet center directors implement processes, and monitors compliance.
No. 15
to Veterans Health Administration (VHA)
Closure Date: 3/25/2022
The District Director determines reasons for noncompliance with staff supervision provided by the vet center directors at the Alexandria, Houston Southwest, Laredo, and Mesquite Vet Centers, ensures staff supervision occurs as required, and monitors compliance.
No. 16
to Veterans Health Administration (VHA)
Closure Date: 9/14/2022
The District Director verifies and determines reasons for noncompliance with monthly RCSnet chart audits at the Alexandria, Houston Southwest, Laredo, and Mesquite Vet Centers, ensures chart audits are completed as required, and monitors compliance.
No. 17
to Veterans Health Administration (VHA)
Closure Date: 3/25/2022
The District Director determines reasons why completed trainings are not being recorded for employees at the Alexandria, Laredo, and Mesquite Vet Centers, ensures all staff complete mandatory trainings, and monitors compliance.
No. 18
to Veterans Health Administration (VHA)
Closure Date: 3/25/2022
The District Director evaluates and determines reasons for noncompliance with tactile (braille) signage at the Alexandria, Houston Southwest, Laredo, and Mesquite Vet Centers and ensures all exit doors are compliant with Architectural Barriers Act requirements.
No. 19
to Veterans Health Administration (VHA)
Closure Date: 3/25/2022
The District Director reviews reasons for noncompliance related to the Mesquite Vet Center’s emergency and crisis plan not containing all required components and ensures compliance.
No. 20
to Veterans Health Administration (VHA)
Closure Date: 3/25/2022
The District Director reviews reasons for noncompliance with securing confidential and sensitive information at the Houston Southwest Vet Center and ensures all vet center employees safely and securely store personally identifiable information.
Date Issued
|
Report Number
21-01805-286
|
Topics: Suicide Prevention
Related Media: Video
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 5/26/2022
The District Director determines reasons clinical quality review remediation plans were not completed, ensures completion, and monitors compliance.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 5/26/2022
The District Director determines reasons administrative quality review remediation plans were not completed, ensures completion, and monitors compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 3/25/2022
The District Director evaluates the process for resolution of administrative quality review deficiencies and initiates action as necessary.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 5/26/2022
The District Director determines reasons why critical incident quality reviews (currently known as morbidity and mortality reviews) for serious suicide attempts were not completed, ensures completion, and monitors compliance.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 3/25/2022
The District Director ensures the intake portion of the psychosocial assessment is completed and monitors compliance across all zone vet centers.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 8/16/2022
The District Director ensures lethality risk assessments are completed on the first clinical visit and monitors compliance across all zone vet centers.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 5/26/2022
The District Director, in collaboration with Readjustment Counseling Service Central Office evaluates the limitations of current tools and tracking methods including why completion dates are not available in RCSnet and ensures compliance with standards for timely completion of intake assessments, military histories, and lethality risk assessments.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 5/26/2022
The District Director ensures clinical staff consult and coordinate care with the support VA medical facility for shared clients flagged as high risk for suicide and monitors compliance across all zone vet centers.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 5/26/2022
The District Director verifies clinical staff follow confidentiality requirements when consulting and coordinating care with the support VA medical facility for shared clients at high risk for suicide and monitors compliance across all zone vet centers.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 5/26/2022
The District Director confirms clinical staff make timely notification to the suicide prevention coordinator at the support Veterans Affairs medical facility for clients with significant safety risks and monitors compliance across all zone vet centers.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 5/26/2022
The District Director ensures clinical staff consult with the Vet Center Director, external clinical consultant, or VA suicide prevention coordinator following a client’s lethality status change as required, and monitors compliance across all zone vet centers.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 5/26/2022
The District Director ensures clinical staff complete crisis reports as required and monitors compliance across all zone vet centers.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 3/25/2022
The District Director, in collaboration with the support VA medical facility clinical or administrative liaisons, determines the reasons for noncompliance with staff participation on the mental health council for the Central Oregon Vet Center and takes actions as indicated to ensure compliance with Readjustment Counseling Service requirements.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 5/26/2022
The District Director determines reasons for noncompliance with High Risk Suicide Flag SharePoint site requirements and the tracking of continuity of care for clients with a high risk suicide flag at the Bellingham Vet Center, takes action to ensure requirements are met, and monitors compliance.
No. 15
to Veterans Health Administration (VHA)
Closure Date: 3/25/2022
The District Director determines reasons the Bellingham Vet Center did not have a written crisis plan, ensures requirements related to crisis plans are met and monitors compliance.
No. 16
to Veterans Health Administration (VHA)
Closure Date: 3/25/2022
The District Director determines reasons for noncompliance with the appointment of a clinical liaison at the Tacoma Vet Center, ensures assignment of a liaison, and monitors compliance.
No. 17
to Veterans Health Administration (VHA)
Closure Date: 5/26/2022
The District Director determines reasons a process for completing and tracking four hours of external clinical consultation per month did not occur at the Bellingham, Central Oregon, Tacoma, and Wasilla Vet Centers, ensures Vet Center Directors implement processes, and monitors compliance.
No. 18
to Veterans Health Administration (VHA)
Closure Date: 5/26/2022
The District Director determines reasons for noncompliance with staff supervision provided by vet center directors at the Bellingham, Central Oregon, Tacoma, and Wasilla Vet Centers, ensures staff supervision occurs as required, and monitors compliance.
No. 19
to Veterans Health Administration (VHA)
Closure Date: 8/16/2022
The District Director verifies and determines reasons for noncompliance with monthly RCSnet chart audits at the Bellingham, Central Oregon, Tacoma, and Wasilla Vet Centers, ensures chart audits are completed as required, and monitors compliance.
No. 20
to Veterans Health Administration (VHA)
Closure Date: 3/25/2022
The District Director determines reasons employees at the Bellingham, Central Oregon, Tacoma, and Wasilla Vet Centers did not complete required trainings, ensures all staff complete mandatory trainings, and monitors compliance.
No. 21
to Veterans Health Administration (VHA)
Closure Date: 3/25/2022
The District Director evaluates and determines reasons for noncompliance with a presentable exterior at the Wasilla Vet Center and ensures all exterior grounds are in good repair.
No. 22
to Veterans Health Administration (VHA)
Closure Date: 5/26/2022
The District Director evaluates and determines reasons for noncompliance with tactile (braille) signage at the Bellingham, Central Oregon, Tacoma, and Wasilla Vet Centers and ensures all exit doors are compliant with Architectural Barriers Act requirements.
No. 23
to Veterans Health Administration (VHA)
Closure Date: 3/25/2022
The District Director reviews reasons for noncompliance with securing confidential and sensitive information at the Bellingham and Tacoma Vet Centers and ensures all vet center employees safely and securely store protected health information.
Date Issued
|
Report Number
21-00268-273
|
Topics: Care Coordination
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 5/27/2022
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine reasons for noncompliance and make certain that all transfers are monitored and evaluated as part of Veterans Health Administration’s Quality Management Program.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 5/27/2022
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine additional reasons for noncompliance and ensure that staff use the VA Inter-Facility Transfer Form or an equivalent note to document inter-facility transfers.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 2/16/2023
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that referring physicians record all required elements in the electronic health record prior to patient transfers.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 5/27/2022
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine the reasons for noncompliance and ensure staff send pertinent medical records, including an active patient medication list, to the receiving facility during inter-facility transfers.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 5/2/2024
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
21-00266-281
|
Topics: Care Coordination
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 11/29/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures the Chief of Staff regularly attends Surgical Performance Improvement Committee meetings.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 5/25/2022
The 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. 3
to Veterans Health Administration (VHA)
Closure Date: 3/4/2022
The System Director evaluates and determines additional reasons for noncompliance and maintains a current written policy to ensure the safe, appropriate, orderly, and timely transfer of patients.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 11/29/2022
The Chief of Staff and Associate Director for Nursing and Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure all transfers are monitored and evaluated as part of Veterans Health Administration’s Quality Management Program.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 11/29/2022
The System Director and Associate Director for Nursing and Patient Care Services evaluate and determine any additional reasons for noncompliance and make certain that referring physicians identify the receiving physicians on the Inter-Facility Transfer Form or facility-defined equivalent note.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 11/29/2022
The Chief of Staff and Associate Director for Nursing and Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure nurse-to-nurse communication occurs during the inter-facility transfer process.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 8/24/2022
The Chief of Staff and Associate Director for Nursing and Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure all required representatives attend Disruptive Behavior Committee meetings.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 1/12/2024
The System Director evaluates and determines any additional reasons for noncompliance and makes certain that staff complete the required prevention and management of disruptive behavior training based on the risk level assigned to their work areas.
Date Issued
|
Report Number
21-00272-283
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 12/20/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures all core members consistently attend Surgical Work Group meetings.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/28/2023
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that employees complete all required prevention and management of disruptive behavior training based on the risk level assigned to their work areas.