Recommendations
514
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 23-01583-183 | Ineffective Oversight of Community Care Providers’ Special-Authorization Drug Prescribing Increased Pharmacy Workload and Veteran Wait Times | Audit | ||
1 Require the Office of Integrated Veteran Care and Pharmacy Benefits Management Services to improve community provider compliance when prescribing special-authorization drugs and being responsive to VA pharmacy inquiries. This should include consideration of electronic system capabilities to attach medical justifications, allow community providers to have real-time access to VA’s formulary when prescribing drugs, and enable two-way communication between community providers and VA pharmacists electronically.
Closure Date:
2 Task the Office of Integrated Veteran Care to train community providers on the VA formulary and implement a process to improve tracking of training completion and community providers’ compliance with VA guidance on submitting prescriptions for special-authorization drugs.
3 Direct Pharmacy Benefits Management Services to update its dashboard to more accurately capture special-authorization drug request processing times and provide the Office of Integrated Veteran Care access to this information for contract management purposes.
Closure Date:
4 Instruct Pharmacy Benefits Management Services to require that VA pharmacy personnel document community care prescriptions for special-authorization drugs in the veteran’s medical record (in consults when applicable or medical notes) when the pharmacy receives the prescription and make clear that the 96-hour processing time is a requirement for these types of drug requests.
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5 Require Pharmacy Benefits Management Services to routinely remind pharmacists that they are responsible for reporting a community provider to the medical facility’s community care office when the provider does not comply with VA documentation requirements for special-authorization drug requests.
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6 Charge facility community care offices to work with pharmacy personnel to report when they receive information from VA pharmacists that community providers did not comply with VA’s documentation requirements for special-authorization drugs. Reporting mechanisms can include submitting Potential Quality Issue Referral reports or Health Care Quality Concern reports to third-party administrators.
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7 Direct Pharmacy Benefits Management Services to standardize requirements for how VA pharmacists code drug requests from community providers in the electronic system that were canceled, rejected, or removed to help VHA determine if corrective actions need to be taken on processes, contract terms, or guidance.
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| 23-01737-205 | Care in the Community Inspection of VA MidSouth Healthcare Network (VISN 9) and Selected VA Medical Centers | Care in the Community Healthcare Inspection | ||
1 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures employees complete the operating model staffing tool reassessment every 90 days.
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2 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff report community care patient safety events in the Joint Patient Safety Reporting system.
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3 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.
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4 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.
5 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility staff attach community diagnostic imaging results to the designated Community Care Consult Result note.
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6 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.
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7 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff make required attempts to obtain medical documentation within 90 days of the appointment after administratively closing consults without medical documentation.
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8 The Veterans Integrated Service Network Director, in conjunction with facility directors, requires facility community care staff to use the significant findings alert when they administratively close community care consults without medical documentation.
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9 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff process community care providers’ requests for services within three business days of receipt.
10 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff assign a level of care coordination to all community care consults as required.
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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 for documenting all care coordination activities for consults with an assigned level of care other than basic.
12 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff change the status of community care consults to active within two business days of the consult’s initial entry or date forwarded to community care staff.
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13 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff schedule patients for community care appointments within the required time frames.
14 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.
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| 23-00539-221 | A Select Review of VHA’s Implementation of the VA Sustainability Plan | National Healthcare Review | ||
1 The Secretary of Veterans Affairs considers incorporating environmental stewardship values into the goals of the Climate- and Sustainability-Focused Federal Workforce priority action in the VA Sustainability Plan to align with Executive Order 14057.
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2 The Under Secretary for Health evaluates the facility-level Green Environmental Management System program manager position, and determines the position’s responsibilities, if any, in the implementation of the VA Sustainability Plan.
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3 The Under Secretary for Health considers broadening the scope of training, education, and engagement of Veterans Health Administration’s workforce to include and incorporate environmental stewardship values.
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4 The Under Secretary for Health encourages continued efforts by the Veterans Health Administration National Anesthesia Service to track and reduce greenhouse gas emissions from inhalational anesthetics and considers evaluation and implementation of a comprehensive waste anesthetic gas mitigation strategy, in pursuit of the VA Sustainability Plan’s priority action goal of achieving net-zero greenhouse gas emissions by 2045.
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5 The Under Secretary for Health considers the relative merits of single-use versus reusable medical devices and evaluates current Veterans Health Administration policy that prohibits the repurposing of single-use medical devices by VA medical centers to increase landfill waste diversion.
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| 23-03531-218 | Failures by Telemetry Medical Instrument Technicians and Leaders’ Response at the VA Eastern Colorado Health Care System in Aurora | Hotline Healthcare Inspection | ||
1 The VA Eastern Colorado Health Care System Director evaluates and ensures that telemetry medical instrument technicians and registered nurses comply with Veterans Health Administration and facility policy requirements for documentation and scanning, specifically related to telemetry oxygenation and rhythm strips and change in patient condition.
2 The VA Eastern Colorado Health Care System Director in conjunction with telemetry nursing leaders, ensures completion of a comprehensive review of the telemetry program and documented oversight of compliance with medical instrument technician monitoring expectations, identifies deficiencies, and takes actions as warranted.
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3 The VA Eastern Colorado Health Care System Director promotes and encourages all staff to use the Joint Patient Safety Reporting system to report patient safety events and ensures telemetry staff and managers are trained on the use of the Joint Patient Safety Reporting system.
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4 The VA Eastern Colorado Health Care System Director evaluates and ensures quality and patient safety event review processes comply with Veterans Health Administration guidance, specifically regarding rejection and follow-up of patient safety reports.
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5 The VA Eastern Colorado Health Care System Director and facility leaders meet all Veterans Health Administration requirements for institutional disclosures for events meeting institutional disclosure criteria.
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6 The VA Eastern Colorado Health Care System Director ensures review of facility clinical alarm management and committee processes, identifies deficiencies, and takes actions as warranted.
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| 23-00749-171 | Unauthorized Community Care Dental Procedures Risked Improper Payments | Audit | ||
1 Ensure all community dentists who provide dental care to veteran patients are notified and periodically reminded of the preauthorization requirements for any changes to treatment plans.
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2 Conduct expanded postpayment reviews to identify and recover payments for unauthorized dental procedures.
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3 Monitor VA dentists to make sure they include required dental procedure codes, not only general descriptions or Standardized Episodes of Care, on referrals to identify the procedures community dentists are authorized to perform.
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4 Review the current contract language and determine if there is a need to clarify the third-party administrators’ claims adjudication responsibilities in its contracts to include the identification of unauthorized dental procedures and adjudication of possible denials of payment or implement controls within VA that will perform this adjudication function for dental claims.
5 Enable the Office of Finance’s automated payment system to deny payment for community dental services if the procedure codes on the dental claims do not fall within the Standardized Episodes of Care on the referral.
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| 24-00160-212 | Deficiencies in Informed Consent for Admission and Against Medical Advice Discharge Processes for a Patient at the VA Southern Nevada Healthcare System in Las Vegas | Hotline Healthcare Inspection | ||
1 The VA Southern Nevada Healthcare System Director develops a process consistent with Veterans Health Administration Directive 1004.01(3) to ensure patients are informed, prior to voluntary admission to the inpatient mental health unit, that the unit is locked and provides services to patients with mental health disorders.
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2 The VA Southern Nevada Healthcare System Director ensures staff are educated following development of the informed consent process for voluntary admission to the inpatient mental health unit.
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3 The VA Southern Nevada Healthcare System Director confirms that medical center policy 116-22-10 adheres to Nevada state law relevant to admission to mental health units and is approved in accordance with Veterans Health Administration policies.
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4 The VA Southern Nevada Healthcare System Director confirms that medical center policy 116-22-10 includes the responsible owners’ oversight and guidance responsibilities as required by Veterans Health Administration Directive 0999(1).
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5 The VA Southern Nevada Healthcare System Director ensures staff education regarding changes to the medical center policy 116-22-10.
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6 The VA Southern Nevada Healthcare System Director ensures that any facility policies involving state law addressing voluntary or involuntary mental health commitments be reviewed by the Office of General Counsel.
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7 The VA Southern Nevada Healthcare System Director develops a process to ensure facility policies adhere to the Veterans Health Administration Directive 0999(1), medical center policy standardized template.
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| 23-01601-208 | Insufficient Mental Health Treatment and Access to Care for a Patient and Review of Administrative Actions in Veterans Integrated Service Network 10 | Hotline Healthcare Inspection | ||
1 The Ann Arbor VA Medical Center Director conducts a full review of the patient’s spring to fall 2017 mental health care to identify quality of care improvement opportunities related to inpatient psychiatrist 2’s medical decision-making, staff’s pre-discharge outpatient care planning, and outpatient staff’s collaboration in providing treatment and engagement efforts including the mental health treatment coordinator assignment and role, and takes actions as warranted.
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2 The Battle Creek VA Medical Center Director ensures staff awareness and access to eligibility verification procedures.
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3 The Battle Creek VA Medical Center Director expedites the full implementation of the Transfer and Admission Coordination Office including a centralized phone number and monitors compliance with the standardized checklist.
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4 The Battle Creek VA Medical Center Director expedites the completion and implementation of the interfacility transfers standard operating procedure and monitors compliance.
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5 The Battle Creek VA Medical Center Director ensures the mental health residential rehabilitation treatment program standard operating procedure is aligned with Veterans Health Administration requirements regarding referral and monitors compliance.
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6 The Veterans Integrated Service Network Director evaluates the efficacy of the Interagency Resolution Council and identification of clearly defined objectives and processes to monitor progress and address identified barriers.
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| 23-00776-207 | Delays and Deficiencies in the Mental Health Care of a Patient at the Michael E. DeBakey VA Medical Center in Houston, Texas | Hotline Healthcare Inspection | ||
1 The VA Houston Health Care System Director evaluates the efficiency of evidence-based psychotherapy consult management procedures; identifies barriers to timely appointment scheduling, including scheduling processes and staffing needs; and takes action as warranted.
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2 The VA Houston Health Care System Director ensures that administrative support staff document scheduling efforts in patients’ electronic health records, as required by the Veterans Health Administration.
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3 The VA Houston Health Care System Director ensures that staff document offering VA-issued devices for participation in virtual mental health appointments in patients’ electronic health records.
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4 The VA Houston Health Care System Director conducts a review of providers’ lethal means safety assessment and planning with the patient, identifies barriers to effective lethal means safety discussions, and takes action as warranted.
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5 The Under Secretary for Health clarifies the expectations and requirements for homeless program staff’s completion of suicide risk assessments and updates or reviews of safety plans for high risk for suicide patients.
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6
The VA Houston Health Care System Director reviews staff’s compliance with high-risk flag patient care requirements, to include updating and reviewing safety plans, following up on failed contacts, and completing suicide risk assessments.
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| 23-03159-204 | Inadequate Care of a Patient Who Died by Suicide on a Medical Unit at the Sheridan VA Medical Center in Wyoming | Hotline Healthcare Inspection | ||
1 The Sheridan VA Medical Center Director ensures completion of warm handoffs and Comprehensive Suicide Risk Evaluations within 24 hours for patients on the medical unit that screen positive on the Columbia-Suicide Severity Rating Scale.
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2 The Sheridan VA Medical Center Director ensures that psychiatry or medical officer of the day staff reassess suicidal patients prior to changing a one-to-one observation status order.
3 The Sheridan VA Medical Center Director ensures that inpatient notes are completed and authenticated by providers as soon as possible, but always within 24 hours, in accordance with facility policy.
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4 The Sheridan VA Medical Center Director ensures that staff follow facility policies for removing belongings and environmental risks for suicidal patients on one-to-one observation status on the medical unit.
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| 23-02958-203 | Care Concerns and Deficiencies in Facility Leaders’ and Staff’s Responses Following a Medical Emergency at the Carl T. Hayden VA Medical Center in Phoenix, Arizona | Hotline Healthcare Inspection | ||
1 The Phoenix VA Health Care System Director ensures Phoenix VA Health Care System rapid response policy is in alignment with Veterans Health Administration Directive 1177, Cardiopulmonary Resuscitation.
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2 The Phoenix VA Health Care System Director ensures Phoenix VA Health Care System policies and procedures related to responding to medical emergencies do not conflict.
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3 The Phoenix VA Health Care System Director ensures Phoenix VA Health Care System policy is in alignment with Veterans Health Administration Directive 1101.14, Emergency Medicine.
4 The Phoenix VA Health Care System Director ensures layperson cardiopulmonary resuscitation training is offered in accordance with Veterans Health Administration Directive 1177, Cardiopulmonary Resuscitation.
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5 The Phoenix VA Health Care System Director determines the need for, and implements placement of, public access automated external defibrillators in accordance with Veterans Health Administration Directive 1177, Cardiopulmonary Resuscitation
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6 The Phoenix VA Health Care System Director assesses outpatient clinic compliance with vital sign completion and documentation, identifies deficiencies, and takes action as warranted.
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7 The Phoenix VA Health Care System Director reviews and assesses the need for non-clinical staff training on the use of the Joint Patient Safety Reporting system, and takes action as warranted.
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8 The Phoenix VA Health Care System Director ensures complaints are reviewed and addressed in accordance with Veterans Health Administration Directive 1003.04, VHA Patient Advocacy.
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9 The Phoenix VA Health Care System Director reviews organizational communication channels and ensures consistency with Veterans Health Administration high reliability organization principles and I CARE values
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10 The Phoenix VA Health Care System Director makes certain that investigation and closure of events placed into the Joint Patient Safety Reporting system are completed per the Veterans Health Administration’s established time frame, and monitors compliance.
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