Recommendations
2178
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 25-04450-218 | Review of a Patient’s Discharge from the Central Virginia VA Health Care System in Richmond | Hotline Healthcare Inspection | ||
1 The Central Virginia VA Health Care System Director evaluates inpatient mental health unit discharge practices and develops processes to assess a caregiver’s capability to ensure a safe discharge.
2 The Central Virginia VA Health Care System Director ensures complaints to the patient advocate are reviewed and addressed in accordance with Veterans Health Administration Directive 1003.04, VHA Patient Advocacy.
3 The Central Virginia VA Health Care System Director ensures medication reconciliation is completed at discharge and during post-discharge encounters according to Veterans Health Administration Directive 1345, Medication Reconciliation.
4 The Central Virginia VA Health Care System Director ensures compliance with Veterans Health Administration Directive 1199, Reporting Cases of Abuse and Neglect, requirements related to clinical staff escalating encounters involving potential abuse and neglect.
5 The Central Virginia VA Health Care System Director conducts a comprehensive review of the patient’s hospitalization and post-discharge encounters and takes action as indicated, including quality management improvement processes.
Closure Date:
6 The Under Secretary for Health considers establishing a process, to be used on non‑business days, that enables Veterans Crisis Line responders to timely escalate concerns of non‑imminent abuse to a mandated reporter.
Closure Date:
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| 25-00258-217 | Healthcare Facility Inspection of the Montana VA Healthcare System in Fort Harrison | Healthcare Facility Inspection | ||
1 The Associate Director keeps patient care areas clean and stores dirty and clean items separately.
Closure Date:
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| 25-02228-172 | Review of VBA’s Unidentifiable Mail Certification Process | Review | ||
1 Update the Adjudication Procedures Manual to require documentation of each specific action taken when staff certify mail as unidentifiable.
2 Provide all employees who process unidentified mail appropriate access to all systems and resources necessary to identify a claimant.
3 Implement a plan to ensure all Veterans Benefits Administration contact and correspondence with claimants is documented and stored as required by the Adjudication Procedures Manual. As part of this plan, ensure documentation is easily accessible to appropriate staff.
4 Provide claims assistants who process unidentified mail with consistent quality reviews specific to their handling of unidentified mail.
5 Consider implementing a training module on processing unidentified mail, including guidance on appropriate work credit for claims assistants, and incorporating it into the national training curriculum. This training could be beneficial for all personnel involved in mail processing, including supervisors and records management officers.
Total Monetary Impact of All Recommendations
Open: $822,468
Closed: $0
Total: $822,468
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| 25-01098-103 | Audit of Program Management for the Benefits Enterprise Platform Modernization | Audit | ||
1 Develop and maintain a Benefits Enterprise Platform modernization program schedule that (1) captures both agile and nonagile tasks and (2) documents the time frame for the delivery of all system modernization requirements.
2 Ensure staff follow VA’s Product (Line) Accountability and Reporting System Guide to include all program schedule information in the System.
3 Develop reliable, validated life cycle cost estimates for the Benefits Enterprise Platform modernization program that support planning and budgeting as required by Office of Management and Budget Circulars A-130 and A‑11.
4 Include all Benefits Enterprise Platform modernization costs in the VA’s Product (Line) Accountability and Reporting System as required by the Veteran-Focused Integration Process Guide, and track Cost of War Toxic Exposures Fund obligations and expenditures in the Office of Information and Technology PACT Act Dashboard consistent with VA financial policy.
5 Establish a mechanism for enforcing VA policy that requires minor applications to include an approved security assessment before being placed on VA’s network.
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| 25-04052-222 | Healthcare Facility Inspection of the VA Asheville Health Care System in North Carolina | Healthcare Facility Inspection | ||
1 Facility leaders implement measures to keep all eyewash stations clean and safe for emergency use.
2 Facility leaders implement measures to keep walkways free of obstructions to maintain clear exit routes.
3 The Director updates the facility’s written policy for test result communications to comply with requirements in Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.
Closure Date:
4 The Chief of Staff and Associate Director of Patient Care Services/Nurse Executive develop and implement written workflows for each service that comply with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.
Closure Date:
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| 25-03623-147 | Review of Timeliness of Mental Health Community Care Appointments | Review | ||
1 Consider the need for adjustments to current or for future contractual requirements that would improve mental health appointment timeliness by third-party administrators.
Closure Date:
2 Identify and disseminate best practices used by healthcare systems to contact veterans, evaluate barriers to broader adoption of those practices, and implement a plan that supports consistent use of those best practices to improve scheduling timeliness.
3 Ensure that systems used to identify available community providers capture the full range of preferences that matter to veterans, so scheduling can better align with their individual needs and expectations for care.
4 Evaluate whether the third-party administrator’s network adequacy standards for mental health providers meet demand for both in person and telehealth, and if needed, modify the language to explicitly require sufficient availability of both in‑person and telehealth mental health providers to meet veteran demand.
5 Conduct a review to determine the best approach for increasing external use of available systems by community providers to streamline communication between the Veterans Health Administration and community providers and develop, implement, and monitor an action plan based on the review’s findings.
6 Assess the need for standardized guidance or contractual requirements that prohibit community mental health providers from requesting additional forms containing information already provided in the Veterans Health Administration referral documentation and implement measures to ensure compliance.
Closure Date:
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| 24-00818-208 | Review of VHA Maternity Care Coordination and Women Veterans’ Experience | Hotline Healthcare Inspection | ||
1 The Under Secretary for Health reviews Veterans Health Administration’s compliance with requirements for postpartum care coordination contacts by the maternity care coordinator and implements an action plan to ensure sustained compliance.
2 The Under Secretary for Health reviews Veterans Health Administration maternity care coordinators’ compliance with requirements for postpartum screenings and implements an action plan to ensure sustained compliance.
3 The Under Secretary for Health evaluates concerns regarding community care billing and billing resolution processes for maternity care and implements an action plan as warranted.
4 The Under Secretary for Health evaluates the scheduling and completion of postpartum primary care appointments within three months of delivery and implements an action plan to ensure sustained compliance.
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| 25-00250-210 | Healthcare Facility Inspection of the VA Wichita Healthcare System in Kansas | Healthcare Facility Inspection | ||
1 The Medical Center Director develops service-level workflows for communicating test results.
Closure Date:
2 The Medical Center Director monitors data on the communication of test results to providers and patients as required by VHA Directive 1088(1), Communicating Test Results to Providers and Patients.
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| 25-04102-182 | Review of Facility Leaders’ Oversight of Care Coordination Services within Homeless Programs at the VA Portland Health Care System in Oregon | Hotline Healthcare Inspection | ||
1 The VA Portland Health Care System Director ensures the Community Reintegration Services director and Health Care for Homeless Veterans program coordinator establish a process to monitor and verify case managers comply with monthly veteran contacts as required by the facility’s HCHV Case Management Workflow Guide, and takes action as warranted.
2 The VA Portland Health Care System Director ensures Health Care for Homeless Veterans staff discharge veterans from the Health Care for Homeless Veterans program in accordance with the facility’s HCHV Case Management Workflow Guide.
3 The VA Portland Health Care System Director reviews the quality management evaluations, once completed, for Veteran A’s and Veteran B’s care, and takes action as warranted.
Closure Date:
4 The VA Portland Health Care System Director evaluates the Community Reintegration Services reporting structure and resources to determine if the current structure allows for effective oversight of essential homeless programs, and makes modifications if needed.
Closure Date:
5 The VA Portland Health Care System Director ensures the Community Reintegration Services director monitors and verifies Grant and Per Diem liaisons’ compliance with Veterans Health Administration Directive 1162.01 requirements related to conducting veteran contacts.
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| 25-02645-131 | Review of Assignment of Noncompensable Musculoskeletal Joint Disabilities | Review | ||
1 Consult with the VA Office of General Counsel to establish a clear and consistent interpretation of 38 C.F.R. § 4.59, to include clarification of whether pain alone without painful motion is sufficient to warrant a compensable evaluation.
2 Based on the clarified interpretation of 38 C.F.R. § 4.59, consider revising the Adjudication Procedures Manual to improve consistency of terms, and notify claims processors of the revision.
3 Assess whether guidance is clear to claims processors regarding the requirement to review all evidence, including both objective and subjective evidence, as well as the proper weight that should be given to each piece of evidence.
4 Determine what actions are necessary to the evaluation builder tool to mitigate confusion and ensure decision consistency for all musculoskeletal joint conditions.
Total Monetary Impact of All Recommendations
Open: $44,979,787
Closed: $0
Total: $44,979,787
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15570