Care in the Community Inspection of VA Sierra Pacific Network (VISN 21) and Selected VA Medical Centers

Report Information

Issue Date
Report Number
24-00566-16
VISN
21
State
American Samoa
California
Guam
Hawaii
Nevada
Northern Mariana Islands
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Care in the Community Healthcare Inspection
Report Topic
Appointment Scheduling and Wait Times
Care Coordination
Community Care
Patient Safety
Major Management Challenges
Healthcare Services
Recommendations
13
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 seven VA Sierra Pacific Veterans Integrated Service Network (VISN) 21 medical facilities with a community care program. 

This evaluation focused on five domains:
   •    Leadership and Administration of Community Care
   •    Community Care Diagnostic Imaging Results
   •    Administratively Closed Community Care Consults
   •    Community Care Provider Requests for Additional Services
   •    Care Coordination: Scheduling and Communication with Patients Referred for Community Care

The OIG issued 13 recommendations for improvement in the five domains:
   •    Leadership and Administration of Community Care
      o    Community oversight councils functioning according to charters
      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    Using the significant findings alert for abnormal diagnostic imaging results
   •    Administratively Closed Community Care Consults
      o    Confirming patients attended appointments obtaining medical documents
      o    Making two attempts to obtain medical documents after administratively closing consults
   •    Community Care Provider Requests for Additional Services
      o    Processing requests
      o    Sending approval and denial letters to community providers and patients
   •    Care Coordination: Scheduling and Communication with Patients Referred for Community Care
      o    Timely scheduling of patients
      o    Confirming patients attended appointments
      o    Using the Community Care–Care Coordination Plan note to document care coordination activities

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/30/2025

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

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/30/2025

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. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/30/2025

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. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/30/2025

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

No. 5
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. 6
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 confirm patients attended their appointments and attempt to obtain medical documentation prior to administratively closing consults.

No. 7
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 closure of consults that are not low risk.

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 process community care providers’ requests for additional services within three business days of receipt.

No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/30/2025

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

No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/30/2025

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff send approval or denial letters to patients for requests for additional services.

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 schedule patients for community care appointments within seven days of consult entry or receipt in the department.

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 confirm patients attended scheduled community care appointments and received care.

No. 13
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 use the Community Care–Care Coordination Plan note to document all care coordination activities for consults with an assigned level of care other than basic.