Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 21-02750-63 | Public Disability Benefits Questionnaires Reinstated but Controls Could Be Strengthened | Review | ||
1 Revise the Veterans Benefits Administration’s adjudication procedures manual to clarify and communicate steps that claims processors must take to ensure all certification elements on the publicly available disability benefits questionnaires are provided and are authentic.
Closure Date:
2 Update the Veterans Benefits Administration’s adjudication procedures manual to clarify the intent of guidance involving authenticity, face value, and validation of publicly available disability benefits questionnaires to ensure claims processors evaluate the questionnaires in accordance with evidentiary principles
Closure Date:
3 Implement actions to facilitate claims processors’ understanding of the need to document the evaluation of evidence within benefits entitlement decisions when using publicly available disability benefits questionnaires.
Closure Date:
4 Amend the Veterans Benefits Administration’s adjudication procedures manual to define valid rationale to ensure medical opinions are well supported when deciding entitlement to benefits.
Closure Date:
5 Correct all processing errors on cases identified by the review team and report the results to the Office of Inspector General.
Closure Date:
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| 21-00280-89 | Comprehensive Healthcare Inspection of the Hunter Holmes McGuire VA Medical Center in Richmond, Virginia | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the Systems Redesign and Improvement Coordinator tracks facility-level improvement capabilities and projects.
Closure Date:
2 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that staff complete a final peer review within 120 calendar days from the date it is determined that a peer review is needed, or the Medical Center Director approves an extension request in writing.
Closure Date:
3 The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that the Peer Review Committee recommends improvement actions for Level 3 peer reviews.
Closure Date:
4 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that the Surgical Work Group reviews surgical deaths.
Closure Date:
5 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that staff monitor and evaluate inter-facility transfers.
Closure Date:
6 The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure transferring providers complete all required elements of the VA Inter-Facility Transfer Form or a facility-defined equivalent prior to patient transfers.
Closure Date:
7 The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and make certain that staff send pertinent medical records, including an active patient medication list, to the receiving facility during inter-facility transfers.
Closure Date:
8 The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure all required representatives attend Disruptive Behavior Committee meetings
Closure Date:
9 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures staff complete all required prevention and management of disruptive behavior training based on the risk level assigned to their work area.
Closure Date:
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| 21-00289-90 | Comprehensive Healthcare Inspection of the James J. Peters VA Medical Center in Bronx, New York | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Peer Review Committee submits a quarterly summary analysis for review by the Medical Executive Committee.
Closure Date:
2 The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that required members attend Facility Surgical Workgroup meetings.
Closure Date:
3 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Facility Surgical Workgroup reviews surgical deaths and evaluates critical surgical events as required.
Closure Date:
4 The Chief of Staff and Nurse Executive (ADPCS/Chief Nurse Executive) evaluate and determine any additional reasons for noncompliance and ensure all required members attend Disruptive Behavior Committee meetings.
Closure Date:
5 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures staff complete all required prevention and management of disruptive behavior training based on the risk level assigned to their work areas.
Closure Date:
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| 21-01506-76 | Comprehensive Healthcare Inspection Summary Report: Evaluation of Mental Health in Veterans Health Administration Facilities, Fiscal Year 2020 | National Healthcare Review | ||
1 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that facility providers conduct four follow-up visits, either face-to-face or telephonic with documented patient preference, within the required time frame.
Closure Date:
2 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures providers collaborate with suicide prevention coordinators when follow-up contact is unsuccessful for high-risk patients.
Closure Date:
3 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that employees complete initial suicide risk and intervention training within 90 days of hire and annual suicide prevention refresher training.
4 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that all facility suicide prevention coordinators complete at least five outreach activities per facility each month.
Closure Date:
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| 20-03086-70 | First-Party Billing Address Management Needs Improvement to Ensure Veteran Debt Notification before Collection Actions | Review | ||
1 Develop and execute a project management plan to evaluate and correct Veterans Health Information Systems and Technology Architecture address data used to mail first-party billing statements.
Closure Date:
2 Establish controls to periodically review and reconcile Veterans Health Information Systems and Technology Architecture address data used to mail first-party billing statements.
3 Improve policies detailing roles, responsibilities, and procedures for remediating returned billing statements and steps for flagging and updating outdated billing addresses
Closure Date:
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| 21-01724-84 | Care in the Community Consult Management During the COVID-19 Pandemic at the Martinsburg VA Medical Center in West Virginia | Hotline Healthcare Inspection | ||
1 The Veterans Integrated Service Network Director confirms that weekly calls with facility and Veterans Integrated Service Network leaders are held to discuss active Improvement Action Plans, progress made, timelines, and next steps.
Closure Date:
2 The Martinsburg VA Medical Center Director verifies that Improvement Action Plans, identifying areas of improvement and outlining recommendations, are in place for unmet national Care in the Community performance metrics.
Closure Date:
3 The Martinsburg VA Medical Center Director ensures COVID Priority 1 consults are run and reviewed by Care in the Community managers and staff daily.
Closure Date:
4 The Martinsburg VA Medical Center Director confirms that clinical reviews of COVID Priority 1 active consults are completed and documented, monitors compliance, and takes action as warranted.
Closure Date:
5 The Martinsburg VA Medical Center Director ensures a process is in place to review and address consults for patients who died prior to being scheduled or seen by a community care provider to determine if an adverse event occurred as a result of a delay in processing a patient’s consult.
Closure Date:
6 The Martinsburg VA Medical Center Director evaluates the effectiveness of strategies to manage the backlog of active consults and the use of urgent and emergent to prioritize consults for scheduling, determines if changes in practice are warranted, and documents the agreed upon process.
Closure Date:
7 The Martinsburg VA Medical Center Director conducts a review to determine who, outside Care in the Community staff, is facilitating appointment scheduling and evaluates if the scheduling assistance of other services is an effective use of resources, and establishes a standardized process to align practices.
Closure Date:
8 The Martinsburg VA Medical Center Director ensures Care in the Community staffing levels are adequate to support the processing of consults according to time frames set by the Veterans Health Administration.
Closure Date:
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| 21-02492-77 | Lack of Care Coordination and Hepatocellular Carcinoma Surveillance of a Patient at the VA Eastern Colorado Health Care System in Aurora | Hotline Healthcare Inspection | ||
1 The VA Eastern Colorado Health Care System Director reviews the transition in care process for patients transferring between primary care providers to ensure continuous care that facilitates communication and avoids missed opportunities, and takes action as warranted.
Closure Date:
2 The VA Eastern Colorado Health Care System Director ensures that providers develop and update patient problem lists as required and monitors compliance.
Closure Date:
3 The VA Eastern Colorado Health Care System Director ensures that primary care providers are educated on the expectations of reviewing a patient’s electronic health record when assuming care of an established patient.
Closure Date:
4 The VA Eastern Colorado Health Care System Director conducts a clinical review of the patient’s care by the primary care providers, determines if an adverse event occurred, and takes action as warranted.
Closure Date:
5 The VA Eastern Colorado Health Care System Director conducts a clinical review of the patient identified during the inspection who did not receive hepatocellular carcinoma surveillance or varices monitoring, determines if an adverse event occurred, and takes action as warranted.
Closure Date:
6 The VA Eastern Colorado Health Care System Director ensures that patients requiring hepatocellular carcinoma surveillance and varices monitoring receive the recommended imaging studies, lab tests, and esophagogastroduodenoscopies, and monitors compliance.
Closure Date:
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| 21-00298-72 | Comprehensive Healthcare Inspection of the VA Hudson Valley Health Care System in Montrose, New York | Comprehensive Healthcare Inspection Program | ||
1 The System Director evaluates and determines any additional reasons for noncompliance and makes certain that final peer reviews are completed within 120 calendar days or have a written extension request approved by the Director.
Closure Date:
2 The System Director evaluates and determines any additional reasons for noncompliance and makes certain that a written policy is in place to ensure the safe, appropriate, orderly, and timely transfer of patients.
Closure Date:
3 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the referring physician includes all required elements on the VA Inter-Facility Transfer Form or facility-defined equivalent note in the patient’s electronic health record.
Closure Date:
4 The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure staff send pertinent medical records to the receiving facility during inter-facility transfers.
Closure Date:
5 The Associate Director for Patient Care Services determines any additional reasons for noncompliance and makes certain that nurse-to-nurse communication occurs between sending and receiving facilities.
Closure Date:
6 The System Director evaluates and determines any additional reasons for noncompliance and ensures Employee Threat Assessment Team members complete required trainings.
Closure Date:
7 The System Director evaluates and determines any additional reasons for noncompliance and ensures employees complete all required prevention and management of disruptive behavior training based on the risk level assigned to their work areas.
Closure Date:
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| 21-00276-67 | Comprehensive Healthcare Inspection of the Durham VA Health Care System in North Carolina | Comprehensive Healthcare Inspection Program | ||
1 The Executive Director evaluates and determines any additional reasons for noncompliance and ensures that credentialing staff complete primary source verification of all registered nurses’ licenses prior to initial appointment.
Closure Date:
2 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that staff complete mandatory suicide safety plan training prior to developing suicide safety plans.
Closure Date:
3 The Chief of Staff and Associate Director Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure that inter-facility transfers are monitored and evaluated.
Closure Date:
4 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that appropriately privileged providers complete the VA Inter-Facility Transfer Form or a facility-defined equivalent note, and document all required elements prior to patient transfers.
Closure Date:
5 The Chief of Staff and Associate Director Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure that transferring providers send patients’ active medication lists to receiving facilities.
Closure Date:
6 The Chief of Staff and Associate Director Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure all required members attend Disruptive Behavior Committee meetings.
Closure Date:
7 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Disruptive Behavior Committee documents patient notification for an Order of Behavioral Restriction in the Disruptive Behavior Reporting System.
Closure Date:
8 The Executive Director evaluates and determines any additional reasons for noncompliance and ensures staff complete the assigned prevention and management of disruptive behavior training based on the risk level assigned to their work area.
Closure Date:
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| 21-00292-73 | Comprehensive Healthcare Inspection of the Louis A. Johnson VA Medical Center in Clarksburg, West Virginia | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director evaluates and determines any additional reasons for noncompliance and designates a systems redesign and improvement coordinator.
Closure Date:
2 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the Chief of Staff regularly attends Surgical Work Group meetings.
Closure Date:
3 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that the referring physician completes all required elements of the VA Inter-Facility Transfer Form or facility-defined equivalent prior to patient transfer.
Closure Date:
4 The Associate Director of Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures nurse-to-nurse communication occurs between sending and receiving facilities.
Closure Date:
5 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures employees complete all required prevention and management of disruptive behavior training based on the risk level assigned to their work areas.
Closure Date:
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15039