Recommendations
2082
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 20-01521-48 | Deficiencies in Inpatient Mental Health Care Coordination and Processes Prior to a Patient’s Death by Suicide, Harry S. Truman Memorial Veterans’ Hospital in Columbia, Missouri | Hotline Healthcare Inspection | ||
1 The Harry S. Truman Memorial Veterans’ Hospital Director strengthens the processes for collaboration between Inpatient Mental Health Unit staff and Vet Center providers for shared patients including for collateral information and discharge planning.
Closure Date:
2 The Harry S. Truman Memorial Veterans’ Hospital Director ensures that Inpatient Mental Health Unit staff collaboratively develop safety plans with patients, including asking the patient directly about access to lethal means.
Closure Date:
3 The Harry S. Truman Memorial Veterans’ Hospital Director continues to monitor the communication of suicide risk assessment results in the hand-off process across clinical settings and takes action as necessary.
Closure Date:
4 The Harry S. Truman Memorial Veterans’ Hospital Director monitors compliance with Mental Health Treatment Coordinator standard operating procedures to ensure that Inpatient Mental Health Unit staff assign a Mental Health Treatment Coordinator, as required.
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5 The Harry S. Truman Memorial Veterans’ Hospital Director ensures that issue briefs are comprehensive and accurate.
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6 The Harry S. Truman Memorial Veterans’ Hospital Director conducts a full review of the patient’s final episode of care and determines whether an institutional disclosure is warranted.
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7 The Under Secretary for Health disseminates written guidance broadly to Veterans Health Administration stakeholders to ensure that Vet Center staff are included in the root cause analysis process for suicide-related events of shared patients.
Closure Date:
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| 20-02774-26 | Added Measures Could Reduce Veterans’ Risk of COVID-19 Exposure in Transitional Housing | Review | ||
1 Issue guidance to medical facility staff on how the COVID 19 At Risk Veteran Report should be used to help service providers identify high risk veterans and educate those veterans on the need for extra precautions.
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2 Ensure medical facility staff are monitoring and assisting with the service providers’ implementation of the Centers for Disease Control and Prevention guidance, including updates.
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3 Identify service providers that have not fully implemented the Centers for Disease Control and Prevention’s six feet social distancing guidelines, particularly for sleeping and meal areas, and encourage them to implement alternative measures or use VA options to help mitigate space limitations.
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4 Monitor the availability of personal protective equipment at service providers’ residences, and help develop contingency plans in the event of a prolonged pandemic or surge.
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| 20-00132-28 | Comprehensive Healthcare Inspection of the Charlie Norwood VA Medical Center in Augusta, Georgia | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the Quality, Safety, Value, and Innovation Council monitors implemented improvement actions.
Closure Date:
2 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that all applicable deaths that occur within 24 hours of admission are peer reviewed.
Closure Date:
3 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that root cause analyses include all required review elements and are properly documented in the VHA Patient Safety Information System.
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4 The Medical Center Director determines the reasons for noncompliance and ensures the Patient Safety Manager or designee provides feedback to staff who submit patient safety incidents that result in a root cause analysis.
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5 The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that provider exit review forms are completed within seven calendar days of licensed healthcare professionals’ departure from the medical center.
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6 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the Chief of Police conducts a physical security evaluation of the Emergency Department.
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7 The Assistant Director determines the reasons for noncompliance and ensures signage is in place for all areas where biohazards are present.
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8 The Assistant Director determines the reasons for noncompliance and ensures that occupational exposure to hazardous materials is minimized in decontamination areas.
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9 The Associate Director evaluates and determines any additional reasons for noncompliance and ensures that a safe and clean environment is maintained throughout the Athens VA Clinic.
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10 The Associate Director determines the reasons for noncompliance and ensures that the medication room and housekeeping supply closet at the Athens VA Clinic are secured at all times.
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11 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that personally identifiable information is protected at the Athens VA Clinic.
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12 The Chief of Staff determines the reasons for noncompliance and ensures that policies and procedures are in place for 24 hours a day, 7 days per week gynecological care.
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13 The Chief of Staff determines the reasons for noncompliance and makes certain that each community-based outpatient clinic has at least two designated women’s health primary care providers or arrangements for leave coverage when only one designated provider is available.
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14 The Chief of Staff evaluates and determines additional reasons for noncompliance and ensures the medical center has a designated women’s health clinical liaison at each community-based outpatient clinic.
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15 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that standard operating procedures align with manufacturers’ instructions for use.
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16 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that the Sterile Processing Services Chief reports the annual risk analysis results to the Veterans Integrated Service Network Sterile Processing Services Management Board.
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17 The Associate Director for Patient Care Services evaluates and determines additional reasons for noncompliance and make certain that the Sterile Processing Services staff properly store high-level disinfected endoscopes.
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18 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that all new employees complete Level 1 training within 90 days of hire.
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19 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that the Sterile Processing Services staff receive properly completed competency assessments prior to reprocessing reusable medical equipment.
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20 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that Sterile Processing Services staff receive monthly continuing education.
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| 20-01480-31 | Surgical Service Care Deficiencies in the Critical Care Unit at the Charlie Norwood VA Medical Center in Augusta, Georgia | Hotline Healthcare Inspection | ||
1 The Charlie Norwood VA Medical Center Director evaluates the effectiveness of the current algorithms for critical care unit nurses and surgical intensivists involving post-operative patients and communication with tele-intensive care unit staff during off-hours, and takes action as indicated.
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2 The Charlie Norwood VA Medical Center Director confirms the current on-call policy is evaluated and modified as appropriate to include specific telemedicine intensive care unit processes.
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3 The Charlie Norwood VA Medical Center Director ensures development of a written plan to address responsibilities of medicine and surgery staff caring for post-operative patients in the Critical Care Unit.
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4 The Charlie Norwood VA Medical Center Director requires critical care unit staff receive training on patient safety reporting and review processes, and monitors compliance.
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5 The Charlie Norwood VA Medical Center Director ensures the coordination between the facility quality management and telemedicine intensive care unit staff on required patient care reviews, and evaluates compliance.
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6 The Charlie Norwood VA Medical Center Director requires that current and new critical care unit staff receive telemedicine intensive care unit initial orientation and competency training, and monitors compliance.
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7 The Veterans Integrated Service Network 10 Telemedicine Intensive Care Unit Program Medical Director requires telemedicine intensive care unit staff training on patient safety reporting and patient care review processes, and monitors compliance.
Closure Date:
8 The Veterans Integrated Service Network 10 Telemedicine Intensive Care Unit Program Medical Director ensures the telemedicine intensive care unit and facility quality management staff coordinate on required patient care reviews, and evaluates compliance.
Closure Date:
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| 20-00130-25 | Comprehensive Healthcare Inspection of the Wm. Jennings Bryan Dorn VA Medical Center in Columbia, South Carolina | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that service chiefs’ reprivileging recommendations are based on ongoing professional practice evaluation activities and licensed independent practitioner files contain properly completed evaluation forms with supporting data.
Closure Date:
2 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Medical Executive Board’s decision to recommend continuation of privileges is based on complete ongoing professional practice evaluation results.
Closure Date:
3 The Director evaluates and determines any additional reasons for noncompliance and makes certain that provider exit review forms are completed within seven calendar days of licensed health care professionals’ departure from the medical center.
Closure Date:
4 The Associate Director evaluates and determines any additional reasons for noncompliance and makes certain that staff dispose of contaminated instruments and used medications appropriately.
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5 The Associate Director evaluates and determines any additional reasons for noncompliance and ensures managers remove patient care supplies from shipping cartons and all corrugated boxes prior to putting items in clean storage areas.
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6 The Associate Director evaluates and determines any additional reasons for noncompliance and ensures that staff secure protected health information when transporting laboratory specimens from the clinic to the medical center.
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7 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers complete an aberrant behavior risk assessment that includes a history of substance abuse, mental health problems or disorders, and aberrant drug-related behaviors on all patients prior to initiating long- term opioid therapy.
Closure Date:
8 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers obtain and document informed consent for patients prior to initiating long-term opioid therapy.
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9 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers conduct follow-up assessments that include adherence to the plan of care and effectiveness of interventions within three months of initiating long-term opioid therapy.
Closure Date:
10 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that mental health providers collaborate with the Suicide Prevention Coordinator after unsuccessful contact attempts with patients flagged as high risk for suicide who miss mental health appointments and properly document those efforts.
Closure Date:
11 The Director evaluates and determines any additional reasons for noncompliance and ensures all staff complete annual suicide prevention refresher training
Closure Date:
12 The Chief of Staff determines the reasons for noncompliance and ensures that gynecological care coverage is available 24 hours a day, 7 days per week.
Closure Date:
13 The Director evaluates and determines any additional reasons for noncompliance and makes certain that required members are appointed and attend Women Veterans Health Committee meetings.
Closure Date:
14 The Associate Director Patient Care/Nursing Service evaluates and determines the reasons for noncompliance and ensures that high-level disinfected endoscopes are stored properly.
Closure Date:
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| 20-00608-29 | Posttraumatic Stress Disorder Claims Processing Training and Guidance Need Improvement | Review | ||
1 Determine the actions needed to ensure staff understand evidence-gathering and verification of stressor requirements for posttraumatic stress disorder claims, and monitor the results to ensure effectiveness once those actions are implemented.
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2 Assess whether reorganizing or amending material in the Veterans Benefits Administration’s Manual M21-1, Adjudication Procedures Manual, related to the development of claims involving entitlement to service connection for posttraumatic stress disorder is needed for accurate processing.
Closure Date:
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| 19-09161-02 | Management and Oversight of the Electronic Wait List for Healthcare Services | Audit | ||
1 The Under Secretary for Health has oversight controls developed and implemented to monitor all facilities’ patient care requests that are identified as “unable to schedule” to ensure patients across the Veterans Health Administration are scheduled in a timely manner.
Closure Date:
2 The Under Secretary for Health ensures standard operating procedures are being implemented so that facility employees routinely review and act on patient care requests identified as “unable to schedule” in the consult toolbox.
Closure Date:
3 The Under Secretary for Health makes certain that facility leaders clearly define and oversee procedures on routinely reviewing, monitoring, and addressing transfer entries on the Light Electronic Administrative Framework.
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| 20-01994-18 | Comprehensive Healthcare Inspection Summary Report for Fiscal Year 2019 | National Healthcare Review | ||
1 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility-level senior leaders, ensures that summaries of the peer review committees’ work are reviewed quarterly by medical executive committees.
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2 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that all applicable deaths within 24 hours of admission are peer reviewed.
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3 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that cardiopulmonary resuscitation committees review each resuscitative episode under the facilities’ responsibility and include required elements in reviews.
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4 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures focused professional practice evaluation criteria are defined in advance.
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5 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures service chiefs include the minimum specialty criteria for focused professional practice evaluations of gastroenterology, pathology, nuclear medicine, and radiation oncology practitioners.
Closure Date:
6 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures executive committees of the medical staff document the decision to recommend continuing licensed independent practitioners’ privileges based on ongoing professional practice evaluation results.
Closure Date:
7 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that service chiefs’ privileging determinations are based, in part, on ongoing professional practice evaluation activities.
Closure Date:
8 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that ongoing professional practice evaluations use assessments by providers with similar training and privileges.
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9 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures facility clinical managers clearly define and share in advance the expectations, outcomes, and time frames for focused professional practice evaluations for cause with licensed independent practitioners.
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10 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that inventories of resources and assets that may be needed during an emergency are documented and reviewed annually.
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11 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that monthly and quarterly controlled substances inspection reports are reviewed at least quarterly by the facility committees responsible for quality oversight.
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12 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that electronic access for monitoring and performing controlled substances balance adjustments is limited to appropriate staff.
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13 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that controlled substances inspectors complete monthly physical inspections of controlled substances storage areas on the day initiated.
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14 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that controlled substances inspectors verify controlled substance orders for five randomly selected dispensing activities.
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15 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that controlled substances inspectors verify that drugs listed on the “Destructions File Holding Report” are secured and documented and that there is a corresponding sealed evidence bag for each medication during monthly inspections.
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16 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that controlled substances inspectors verify the inventory count for prescription pads on the day of monthly pharmacy inspections.
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17 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that controlled substances inspectors verify written controlled substances prescriptions during monthly area inspections.
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18 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that controlled substances inspectors verify pharmacy vault inventory at the required frequency.
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19 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that controlled substances inspectors complete emergency drug cache inspections that include checks for lock tampering and verification of lock numbers.
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20 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that clinical managers implement processes for reviewing automated drug dispensing cabinet override reports.
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21 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures military sexual trauma coordinators establish and monitor related training.
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22 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures military sexual trauma coordinators communicate related issues, services, and initiatives to facility leaders.
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23 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures mental health and primary care providers complete mandatory military sexual trauma training within the required time frame.
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24 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that clinicians provide and document education on newly prescribed medications and assess patient/caregiver understanding of the information provided.
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25 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that clinicians review and reconcile patients’ medications and maintain and communicate accurate medication information in electronic health records.
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26 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensure that women veterans health committees include required core members, meet at least quarterly, and report to leadership.
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27 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that clinical managers implement quality assurance processes that include tracking of cervical cancer screening notification and follow-up care.
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28 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that urgent care centers operating 24 hours a day, 7 days a week have an approved waiver from the National Director of Emergency Medicine.
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29 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that emergency departments and urgent care centers are staffed with a minimum of two registered nurses during all hours of operation.
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30 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensure clinical managers maintain a backup call schedule for emergency department and urgent care center providers.
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31 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that support services, including social work, are available to emergency departments and urgent care centers during all hours of operation.
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32 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that facilities use appropriate signage to direct patients to emergency departments and urgent care centers.
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| 19-07316-262 | Homemaker and Home Health Aide Program: Most Claims Paid Correctly, but Opportunities Exist to Improve Services to Veterans | Audit | ||
1 The under secretary for health assess whether current program policies and practices meet the needs of medical facilities’ local homemaker and home health aide programs and update them as necessary.
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2 The under secretary for health updates homemaker and home health aide program guidance to include processes that medical facilities must follow when assessing whether home health agencies are licensed or certified, meet specified conditions, or will be exempted from program requirements, to include determining a mechanism to track data on these decisions locally and nationally.
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3 The under secretary for health updates homemaker and home health aide program guidance to include procedures that medical facilities must follow to determine the suitability of veterans for program services when they cannot meet veterans’ program needs within the required period of time because of facility or community resource constraints.
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4 The under secretary for health implements procedures for medical facility directors to use data on veteran demand, including unmet demand, for homemaker and home health aide program services to manage their local program resources.
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5 The under secretary for health updates homemaker and home health aide program guidance to include processes that medical facilities must complete when veterans with care needs have been refused services from home health agencies because of demonstrated behavioral issues.
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6 The under secretary for health reviews homemaker and home health aide program claims identified in the audit sample that involved improper payments made to home health agencies and recover funds if deemed necessary.
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7 The under secretary for health assesses the timeliness of homemaker and home health aide program claim payments and take corrective action as necessary.
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8 The under secretary for health makes sure there is sufficient monitoring of processed homemaker and home health aide program claims to mitigate the risk of paying claims not consistent with the corresponding authorizations.
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| 20-02826-07 | Enhanced Strategy Needed to Reduce Disability Exam Inventory Due to the Pandemic and Errors Related to Canceled Exams | Review | ||
1 Further develop, implement, and test its strategy to reduce the exam inventory using in person, telehealth, and acceptable clinical evidence exams as safety and circumstances permit.
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2 Develop and implement a plan to increase the use of telehealth exams. VBA should also ensure contractors follow the Office of Disability and Medical Assessment telehealth guidance for exams that determine whether a telepresenter or specific medical equipment is required.
Closure Date:
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15049