All Reports

The Director updates the facility policy for communicating test results in accordance with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Chief of Staff and Associate Director for Patient Care Services develop service-level written workflows in accordance with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Veterans Integrated Service Network Director takes action so that executive leaders establish trust and a culture of safety, in accordance with the Veterans Health Administration High Reliability Organization (HRO) Reference Guide.

The Medical Center Director develops an action plan with community care leaders to meet the requirement for staff to schedule appointments within seven days, as outlined in the Veterans Health Administration’s Consult Timeliness Standard Operating Procedure.

Develop and implement timeliness goals for completing Appeals Modernization Act decision reviews for the Program of Comprehensive Assistance for Family Caregivers to make sure that claims are assigned and acted upon in accordance with these measures.

Develop a plan to address the backlog of Appeals Modernization Act decision reviews for the Program of Comprehensive Assistance for Family Caregivers and report progress routinely and transparently to inform veterans.

Update language in VA Form 10‑305 and VHA Notice 2025-09 to clarify that veterans or caregivers must file a Program of Comprehensive Assistance for Family Caregivers supplemental claim within one year from the date of the decision notification letter to be eligible for the same effective date as the date of their initial application for any benefits granted in accordance with the law (38 U.S.C. § 5110).

Provide findings on the analysis of why Veterans Health Information Systems and Technology Architecture reports do not capture all patient encounters with a reasons-not-billable code and implement a plan to capture all encounters being reported outside that system.

Provide guidance and oversight to ensure reasons-not-billable reports have accurate and complete patient encounter data.

Review encounters excluded from Veterans Health Information Systems and Technology Architecture reasons-not-billable reports for potentially billable encounters and, if appropriate, bill insurance companies for revenue for the period allowed by 38 U.S.C. § 1729.

Review and correct the processing errors on decisions the Office of Inspector General team identified so that they are compliant with 38 C.F.R. § 4.118 and consistent with the Adjudication Procedures Manual.

Initiate and provide a timeline for revising the “Scars/Disfigurement” disability benefits questionnaire to clearly elicit information needed for claims processors to determine whether subjective reports of scar pain or tenderness are supported by objective evidence, as required, to establish a compensable evaluation for a painful scar under the Adjudication Procedures Manual.

Determine and complete additional actions so that employees understand how to accurately evaluate painful scars under 38 C.F.R. § 4.118 and in accordance with the Adjudication Procedures Manual.

The Chief of Staff and Associate Director for Patient Care Services develop written service-level workflows that outline staff members’ roles in the process to communicate test results to patients, in accordance with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Associate Director requires bathroom and shower emergency pull cords to be present, accessible, and functional, in accordance with the National Fire Protection Association’s NFPA 99 Health Care Facilities Code.

The Chief of Staff develops written workflows for each service consistent with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Chief of Staff develops and implements a standardized process to routinely assess panel size and efficiency, as required by Veterans Health Administration Directive 1406(3), Patient Centered Management Module (PCMM) for Primary Care.

The Director develops and implements a process to meet the seven‑day scheduling requirement in Veterans Health Administration’s Consult Timeliness Standard Operating Procedure.

The Director takes appropriate steps to maintain clean patient care areas and properly manage biohazards, in accordance with Veterans Health Administration Directive 1131, Management of Infectious Diseases and Infection Prevention and Controls Programs.

The Director takes appropriate steps so the facility’s annual assessment for Legionella disease prevention includes the Papillion community living center, as required by Veterans Health Administration Directive 1061(4), Prevention of Health Care-Associated Legionella Disease and Scald Injury from Water Systems.

The Chief of Staff takes the appropriate steps for leaders to assess the facility’s pharmaceutical waste disposal processes and reeducate staff on safe handling and disposal practices, in accordance with the facility’s Regulated Waste Materials Management policy and Pharmaceutical Return, Waste, and Disposal Standard Operating Procedure.

The Chief of Staff and Associate Director for Patient Care/Nurse Executive take the appropriate steps so leaders create service-level workflows that outline staff roles for communicating test results to patients and providers, as required by Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Under Secretary for Health implements corrective actions to ensure discharge instructions for veterans consistently include appointment locations in easy-to-understand language.

The Under Secretary for Health implements corrective actions to ensure discharge instructions for veterans who received inpatient mental health care include the purpose for each medication listed and do not include medical abbreviations.

The Under Secretary for Health implements corrective actions to ensure risk-benefit discussions occur for newly prescribed medications.

The Director takes appropriate action for employees to keep patient care areas clean as required by Veterans Health Administration Directive 1608(1), Comprehensive Environment of Care Program and clean storerooms as required by Veterans Health Administration Directive 1761, Supply Chain Management Operations.

The Director takes appropriate action for employees to inspect and test all medical equipment as required by The Joint Commission standard PE [Physical Environment] 04.01.01.

The Director takes appropriate action so pharmaceutical waste containers are provided and accessible, and trains employees on container use as required by Veterans Health Administration Directive 1850.06(1), Waste Management Program.

The Director takes appropriate action so employees secure power strips as required by National Fire Protection Association’s Health Care Facilities Code, NFPA 99 and electrical cords are connected to prevent pulling or straining as required by National Electrical Code, NFPA 70.

The Under Secretary for Health considers including high-risk conditions, such as suspected cancer, to the listing of complex/chronic conditions within the administrative portion of the consult tool outlined in the Veterans Health Administration Office of Integrated Veteran Care (IVC) Community Care Field Guidebook.

Facility leaders take appropriate actions so staff maintain a safe and clean environment, in accordance with Veterans Health Administration Directive 1608(1), Comprehensive Environment of Care Program.

The Chief of Staff and Associate Director for Patient and Nursing Services develop service-level workflows that outline responsibilities in the patient notification process and update the facility’s test result communication policy to align with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Chief of Staff and Associate Director for Patient and Nursing Services implement actions based on external peer review data to improve providers’ communication of test results to patients, in accordance with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Director takes appropriate actions so that staff consistently follow the facility’s Legionella prevention plan and achieve and sustain compliance with all applicable requirements in Veterans Health Administration Directive 1061(4), Prevention of Health Care-Associated Legionella Disease and Scald Injury from Water Systems to prevent contamination and maintain water quality, including testing, documentation, and mitigation actions, to protect resident safety in the community living center.

The Director develops and implements a written policy for communicating test results that aligns with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Chief of Staff and Associate Director for Patient Care Services develop written service-level workflows that align with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Chief of Staff and Associate Director for Patient Care Services take corrective actions to address unfavorable trends in the communication of test results in accordance with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Director evaluates the Healthcare Delivery Board and takes actions when warranted to provide proper oversight of clinical care quality in accordance with Joint Commission standards Medical Staff 16.01.01 and Leadership 11.01.01.

The Chief of Staff and Associate Director for Patient Care Services take appropriate actions to develop written service-level workflows that describe team members’ roles in the process of communicating test results, per Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Chief of Staff and Associate Director for Patient Care Services review performance measure data for test result communications and take corrective action when they identify noncompliance with communicating abnormal test results within seven days, per Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Director performs a comprehensive safety risk assessment of enclosed walkways and implements necessary corrective actions to mitigate slip hazards, in accordance with Veterans Health Administration Directive 1608(1), Comprehensive Environment of Care Program.

The Director takes appropriate actions for staff to regularly identify and remove expired supplies in all areas outside standard supply rooms to comply with Veterans Health Administration Directive 1761, Supply Chain Management Operations.

The Veterans Integrated Service Network Director monitors the facility’s processes to prevent repeat environment of care findings and takes any needed actions to meet the requirements of Veterans Health Administration Directive 1608(1), Comprehensive Environment of Care Program.