Recommendations
2051
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 24-02059-177 | Failures Related to the Care and Discharge of a Patient and Leaders’ Response at the VA New Mexico Healthcare System in Albuquerque | Hotline Healthcare Inspection | ||
1 The VA New Mexico Healthcare System Director ensures that social work staff are knowledgeable that 10-10EZR forms can be completed at any time to correct a patient’s financial information and documents are not required to verify financial information.
2 The VA New Mexico Healthcare System Director reviews the ineffective communication, collaboration, and utilization of available sources of information by social work staff and the enrollment and eligibility supervisor and ensures the ongoing assessment of barriers that could affect patients’ care.
3 The VA New Mexico Healthcare System Director identifies why postsurgical follow-up care was not coordinated for the patient and takes action as warranted.
4 The VA New Mexico Healthcare System Director educates emergency department providers on the expectation for identifying the eligibility of each patient who requires admission and the need to obtain Chief of Staff approval if an ineligible patient necessitates care at the facility.
5 The VA New Mexico Healthcare System Director ensures that inpatient providers are aware of the process to obtain Chief of Staff approval for an ineligible patient to continue care at the facility when clinically indicated.
6 The VA New Mexico Healthcare System Director reviews the process for note retractions and ensures providers and document specialists are trained on the process.
7 The VA New Mexico Healthcare System Director ensures that inpatient social workers, providers, transfer coordinators, and nurses are aware that ineligible patients can be transferred from the facility and provides education related to the processes required for approval and facilitation of the transfer.
8 The VA New Mexico Healthcare System Director monitors compliance with the requirement that discharge paperwork is provided to each patient who is discharged.
9 The VA New Mexico Healthcare System Director ensures that providers communicate relevant information to community healthcare providers as needed to ensure continuity of care.
10 The VA New Mexico Healthcare System Director evaluates that staff (inpatient social workers, providers, transfer coordinators, nurses, and the nursing officer of the day) are aware that ineligible patients can be transported from the facility and provides education related to the processes required for approval and facilitation of the transport.
11 The VA New Mexico Healthcare System Director educates staff on steps to take if attempts to escalate concerns to their supervisors are not adequately addressed.
12 The VA New Mexico Healthcare System Director reviews the facility’s root cause analysis process, ensures that staff directly involved in an adverse event do not participate in root cause analysis of an event, and considers if another root cause analysis should be completed on this event.
13 The VA New Mexico Healthcare System Director makes certain that leaders are aware when assigned as responsible for root cause analysis action items and adhere to action plan due dates.
14 The VA New Mexico Healthcare System Director takes action to ensure that leaders understand and effectively utilize high reliability organization principles noted in this report to identify and correct deficiencies.
15 The VA New Mexico Healthcare System Director monitors the podiatry residency program for compliance with VHA Directive 1400.01 postgraduate year 1 resident supervision requirements.
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| 24-01429-145 | Implementation of a Military Sexual Trauma Operations Center Resulted in Minimal Change Despite Planned Intent to Improve Claims-Processing Accuracy | Review | ||
1 Develop and implement a method to identify and report separate quality statistics for the Military Sexual Trauma Operations Center.
2 Update the existing two-signature review process for claims processors and designated reviewers to include an increased focus on military sexual trauma denials.
3 Develop and implement a process to assess designated reviewers’ competency in processing denied military sexual trauma claims and monitor effectiveness.
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| 24-00825-176 | Care in the Community Inspection of Medical Facilities in VISN 4: VA Healthcare | Care in the Community Healthcare Inspection | ||
1 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.
2 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care leaders complete the staffing tool reassessment every 90 days.
3 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff enter patient safety events into the Joint Patient Safety Reporting system.
4 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.
5 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures staff import all community care documents into patients’ electronic health records within five business days of receipt.
6 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 community providers’ medical documents prior to administratively closing consults.
7 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 documents within 90 days of the appointment following administrative closure of non-low-risk consults.
8 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff process community providers’ requests for additional services within three business days of receipt.
9 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.
10 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.
11 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff create and use the Community Care–Care Coordination Plan note in the electronic health record to document all care coordination activities for consults with an assigned level of care coordination other than basic.
12 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff confirm patients attended their scheduled community care appointments and received care.
13 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff create the Community Care–Urgent Care Record note in the electronic health record when they receive urgent care documents.
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| 24-00824-174 | Care in the Community Inspection of Medical Facilities in VISN 10: VA Healthcare System Serving Ohio, Indiana, and Michigan | Care in the Community Healthcare Inspection | ||
1 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.
2 The Veterans Integrated Service Network Director, in conjunction with facility directors, confirms community care clinical staffing needs and takes action as necessary.
Closure Date:
3 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.
4 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.
5 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures staff import all community care documents into patients’ electronic health records within five business days of receipt.
Closure Date:
6 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 community providers’ medical documents prior to administratively closing consults.
7 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff make two attempts to obtain community providers’ medical documents within 90 days of the appointment following administrative closure of non-low-risk consults.
8 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff process community providers’ requests for additional services within three business days of receipt.
9 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff incorporate supporting medical documents with requests for additional services forms into patients’ electronic health records.
10 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff confirm community providers signed the requests for additional services forms.
11 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff send approval letters to community providers for requests for additional services.
12 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff send approval letters to patients for requests for additional services.
13 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff create and use the Community Care–Care Coordination Plan note to document all care coordination activities for consults with an assigned level of care coordination other than basic.
14 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff confirm patients attended their scheduled community care appointments and received care.
15 Veterans Health Administration creates a process for facility staff notification of patients’ urgent care visits in the community.
16 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff create the Community Care–Urgent Care Record note in electronic health records when they receive urgent care documents.
Closure Date:
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| 24-02690-167 | Deficiencies in Crisis Management of a Client, Crisis Reporting, and Documentation Practices at the Everett Vet Center in Washington | Hotline Healthcare Inspection | ||
1 The District 5 Director conducts a full review of care provided to the client by the Everett Vet Center Director and counselor, consults with Human Resources and General Counsel Offices, and takes action as needed.
2 The District 5 Director ensures vet center leaders and staff are knowledgeable about applicable state laws pertaining to duty to warn.
3 The District 5 Director makes certain that the Everett Vet Center Director and staff adhere to requirements for consultation with support facility external consultants and suicide prevention coordinators when indicated, and monitors compliance.
4 The Chief Officer, Readjustment Counseling Service provides written guidance to clarify crisis reporting criteria and monitoring responsibilities.
5 The Chief Officer, Readjustment Counseling Service establishes written policy that clarifies clinical record documentation requirements regarding entry dates; non-visit progress note completion time frames; and progress note deletion and addition, and monitors compliance.
6 The Chief Officer, Readjustment Counseling Service establishes written guidance regarding time requirements for the completion of risk assessment documentation in clients’ clinical records.
7 The District 5 Director ensures readjustment counselors’ compliance with updating and reviewing safety plans as required by Readjustment Counseling Service policy.
8 The Chief Officer, Readjustment Counseling Service ensures that vet center directors are issued the correct position description and are performing duties within the identified scope of work.
9 The District 5 Director conducts a review of the care provided to complex clients by the Everett Vet Center Director since March 2021 and addresses identified clinical needs.
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| 24-02031-171 | Care in the Community Deficiencies and Ineffective VISN Oversight at the VA Maryland Health Care System in Baltimore | Hotline Healthcare Inspection | ||
1 The Under Secretary for Health assesses the feasibility of the 7-day appointment scheduling requirement for Care in the Community consults and considers stratifying the time frame requirement according to risk.
2 The VA Maryland Health Care System Director develops and implements an education plan to address incomplete Care in the Community consult submissions and monitors efficacy of the plan.
3 The VA Maryland Health Care System Director implements Care in the Community consult management process improvements, focusing on consult completion.
4 The Veterans Integrated Service Network Director assists system leaders with completing corrective actions to improve Care in the Community performance.
5 The VA Maryland Health Care System Director ensures system Care in the Community staff create and use care coordination plan notes for documenting all care coordination activities for consults with an assigned level of care other than basic and monitors for compliance.
6 The VA Maryland Health Care System Director ensures full implementation of Veterans Health Administration’s enhanced Referral Coordination Initiative as required and monitors for compliance.
7 The VA Maryland Health Care System Director ensures Care in the Community Patient Advocate Tracking System data is analyzed for use in service-level quality and process improvement and monitors for compliance.
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| 24-02430-152 | Delays in Pension Automation Updates Led to Some Burial Transportation Benefits Being Incorrectly Processed | Review | ||
1 Update the relevant sections on transportation expenses in the Veterans Benefits Administration’s Adjudication Procedures Manual to align with each other.
Closure Date:
2 Ensure automation is consistent with the policy for processing the transportation benefit.
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| 24-00615-163 | Healthcare Facility Inspection of the Sheridan VA Health Care System in Wyoming | Healthcare Facility Inspection | ||
1 The OIG recommends facility leaders implement tools to help sensory-impaired veterans navigate the facility.
2 The OIG recommends facility leaders ensure the facility has a policy for test result communication that includes methods to monitor the effectiveness of the patient notification process.
3 The OIG recommends facility leaders ensure staff develop workflows for the communication of test results for each service.
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| 24-00613-162 | Healthcare Facility Inspection of the VA Boston Healthcare System in Massachusetts | Healthcare Facility Inspection | ||
1 The OIG recommends the Director ensures staff have processes to prevent repeat environment of care findings.
2 The OIG recommends the Veterans Integrated Service Network 1 Director monitors for similar or repeated environment of care findings and ensures facility staff sustain improvements.
3 The OIG recommends the Veterans Integrated Service Network 1 Director ensures facility leaders identify environment of care trends and establish performance improvement plans with outcome measures to address them.
4 The OIG recommends the Director ensures staff post biological hazard signs on doors where potentially infectious materials may be present.
5 The OIG recommends the Director ensures staff keep patient care areas clean and safe.
6 The OIG recommends the Director ensures only authorized staff have access to medication storage areas.
7 The OIG recommends the Director ensures staff conduct an inventory of all the facility’s medication storage areas, and the Chief of Pharmacy approves them.
8 The OIG recommends the Chief of Pharmacy ensures pharmacy staff inspect each approved medication storage area monthly.
9 The OIG recommends the Director ensures staff monitor temperature and humidity in medication storage areas and track possible deviations, even those that may occur when the areas are closed.
10 The OIG recommends the Director ensures the Brockton VA Medical Center’s Urgent Care Center operates according to VHA Directive 1101.13 and obtains an appropriate waiver from the VHA National Program Office of Emergency Medicine as applicable.
Closure Date:
11 The OIG recommends facility leaders review the local policy to ensure it complies with VHA directives specific to which staff receive notification of critical test results.
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| 24-00610-164 | Healthcare Facility Inspection of the VA Connecticut Healthcare System in West Haven | Healthcare Facility Inspection | ||
1 The OIG recommends facility leaders develop and implement a plan to address veterans’ unanswered phone calls.
2 The OIG recommends the Associate Director ensures staff identify environment of care trends and establish performance improvement plans with outcome measures to address them.
3 The OIG recommends the Associate Director ensures the manufacturer satisfies contractual requirements to perform preventive maintenance for beds and stretchers and documents the service.
4 The OIG recommends the Veterans Integrated Service Network Director works with facility and primary care leaders to address the network call center’s effect on primary care team efficiency and workload and reduce the risk of adverse patient safety events.
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14903