Care in the Community Inspection of VA Desert Pacific Healthcare Network (VISN 22) and Selected VA Medical Centers

Report Information

Issue Date
Report Number
23-01739-26
VISN
22
State
Arizona
California
New Mexico
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Care in the Community Healthcare Inspection
Report Topic
Care Coordination
Community Care
Patient Safety
Staffing
Major Management Challenges
Healthcare Services
Recommendations
12
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary

This Office of Inspector General (OIG) Care in the Community healthcare inspection program report describes the results of a focused evaluation of community care processes at eight VA Desert Pacific Healthcare Veterans Integrated Service Network (VISN) 22 medical facilities with a community care program. 

This evaluation focused on four domains:
   •    Leadership and Administration of Community Care
   •    Community Care Diagnostic Imaging Results
   •    Administratively Closed Community Care Consults
   •    Community Care Provider Requests for Additional Services

The OIG issued 12 recommendations for improvement in the four domains:
   •    Leadership and Administration of Community Care
     o    Community oversight councils functioning according to charters
     o    Completing the operating model staffing tool reassessment
     o    Entering patient safety events in the Joint Patient Safety Reporting system
     o    Briefing patient safety trends, lessons learned, and corrective actions
     o    Scanning community care documents into the electronic health record
   •    Community Care Diagnostic Imaging Results
     o    Attaching diagnostic imaging results to the Community Care Consult Result note
     o    Using the significant findings alert for abnormal results
   •    Administratively Closed Community Care Consults
     o    Making two attempts to obtain medical documents after administrative closure
   •    Community Care Provider Requests for Additional Services
     o    Processing requests
     o    Incorporating requests in the electronic health record
     o    Verifying providers’ signatures on forms
     o    Sending denial letters to community providers

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

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

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/16/2025

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

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/26/2025

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

No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures patient safety managers or designees brief community care patient safety event trends, lessons learned, and corrective actions at community care oversight council meetings.

No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

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

No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/26/2025

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff attach diagnostic imaging results to the Community Care Consult Result note.

No. 7
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director, in conjunction with facility directors, requires facility community care staff to use the significant findings alert to notify the ordering provider of abnormal diagnostic imaging results.

No. 8
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff make two additional attempts to obtain community providers’ medical documentation within 90 days of the appointment following administrative consult closure.

No. 9
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff process community care providers’ requests for additional services within three business days of receipt.

No. 10
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff incorporate requests for additional services and supporting medical documentation in patients’ electronic health records.

No. 11
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff verify community care providers’ signatures on requests for additional services forms.

No. 12
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff send letters to community providers when they deny requests for additional services.