Date Issued
|
Report Number
21-03164-115
|
Topics: Financial Management
All Reports
Date Issued
|
Report Number
21-00656-110
|
Topics: Electronic Health Records Modernization (EHRM)
● Patient Safety
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Electronic Health Record Modernization Integration Office (EHRM IO)
Closure Date: 4/9/2024
The Deputy Secretary ensures that substantiated and unresolved allegations discussed in this report are reviewed and addressed.
No. 2
to Electronic Health Record Modernization Integration Office (EHRM IO)
Closure Date: 9/28/2022
The Deputy Secretary ensures medication management issues related to the new electronic health record that are identified subsequent to this inspection be reported to the Office of Inspector General for further analysis.
Date Issued
|
Report Number
21-00781-109
|
Topics: Electronic Health Records Modernization (EHRM)
● Patient Safety
● Care Coordination
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Electronic Health Record Modernization Integration Office (EHRM IO)
Closure Date: 10/2/2023
The Deputy Secretary ensures that substantiated and unresolved allegations noted in this report are reviewed and addressed.
Date Issued
|
Report Number
21-00781-108
|
Topics: Electronic Health Records Modernization (EHRM)
● Patient Safety
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Electronic Health Record Modernization Integration Office (EHRM IO)
Closure Date: 10/3/2023
The Deputy Secretary completes an evaluation of the new electronic health record problem resolution processes and takes action as warranted.
No. 2
to Electronic Health Record Modernization Integration Office (EHRM IO)
Closure Date: 10/19/2022
The Deputy Secretary completes an evaluation of the underlying factors of substantiated allegations identified in this report and takes action as warranted.
No. 3
to Electronic Health Record Modernization Integration Office (EHRM IO)
The Deputy Secretary ensures the electronic health record modernization deployment schedule reflects resolution of the allegations and concerns discussed in this report.
Date Issued
|
Report Number
21-00281-100
|
Topics: Patient Safety
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 6/23/2023
The Chief of Staff and Associate Director–Patient/Nursing Services evaluate and determine any additional reasons for noncompliance and ensure that staff monitor and evaluate inter-facility patient transfers as part of VHA’s Quality Management Program.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 1/19/2023
The Chief of Staff and Associate Director–Patient/Nursing Services evaluate and determine any additional reasons for noncompliance and ensure that all required members attend Disruptive Behavior Committee meetings.
Date Issued
|
Report Number
21-03325-86
|
Topics: Maintenance and Construction
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to National Cemetery Administration (NCA)
Closure Date: 3/10/2022
Revise the equipment policy to include provisions and timelines to resume routine activities, such as required preventive maintenance checks, which could be affected by natural disasters or emergencies, such as the COVID 19 pandemic.
No. 2
to National Cemetery Administration (NCA)
Closure Date: 9/26/2022
Provide an action plan and timeline to repair the headstones or sod in the 65 gravesites the team identified.
Date Issued
|
Report Number
21-02750-63
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 8/11/2022
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.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 8/11/2022
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
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 8/26/2022
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.
No. 4
to Veterans Benefits Administration (VBA)
Closure Date: 7/21/2022
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.
No. 5
to Veterans Benefits Administration (VBA)
Closure Date: 1/30/2024
Correct all processing errors on cases identified by the review team and report the results to the Office of Inspector General.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 88,700.00
Date Issued
|
Report Number
21-00280-89
|
Topics: Patient Safety
● Care Coordination
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 10/26/2022
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.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 2/8/2023
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.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 8/4/2022
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.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 10/26/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that the Surgical Work Group reviews surgical deaths.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 8/4/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that staff monitor and evaluate inter-facility transfers.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 2/8/2023
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.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 8/4/2023
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.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 10/26/2022
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
No. 9
to Veterans Health Administration (VHA)
Closure Date: 2/8/2023
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.
Date Issued
|
Report Number
20-03814-64
Date Issued
|
Report Number
21-00289-90
|
Topics: Patient Safety
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 3/3/2022
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.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/3/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that required members attend Facility Surgical Workgroup meetings.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 3/3/2022
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.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 8/1/2022
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.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 10/2/2023
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.
Date Issued
|
Report Number
21-01506-76
|
Topics: Suicide Prevention
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 1/5/2023
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.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 1/5/2023
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.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 10/20/2025
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.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 1/5/2023
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.
Date Issued
|
Report Number
20-03086-70
|
Topics: Healthcare Infrastructure
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 3/21/2024
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.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 12/10/2025
Establish controls to periodically review and reconcile Veterans Health Information Systems and Technology Architecture address data used to mail first-party billing statements.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 5/7/2025
Improve policies detailing roles, responsibilities, and procedures for remediating returned billing statements and steps for flagging and updating outdated billing addresses
Date Issued
|
Report Number
21-01724-84
|
Topics: COVID-19
● Community Care
● Care Coordination
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 10/18/2022
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.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 1/18/2023
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.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 10/18/2022
The Martinsburg VA Medical Center Director ensures COVID Priority 1 consults are run and reviewed by Care in the Community managers and staff daily.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 1/18/2023
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.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 7/21/2022
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.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 7/21/2022
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.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 10/18/2022
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.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 10/18/2022
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.
Date Issued
|
Report Number
21-01505-68
|
Topics: Care Coordination
Date Issued
|
Report Number
21-02492-77
|
Topics: Care Coordination
● Patient Safety
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 9/28/2022
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.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/29/2023
The VA Eastern Colorado Health Care System Director ensures that providers develop and update patient problem lists as required and monitors compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 3/29/2023
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.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 9/28/2022
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.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 12/27/2022
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.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 7/10/2023
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.
Date Issued
|
Report Number
21-03260-60
Date Issued
|
Report Number
21-00298-72
|
Topics: Care Coordination
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 7/5/2022
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.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 7/5/2022
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.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 3/28/2023
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.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 9/26/2022
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.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 9/26/2022
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.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 7/5/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures Employee Threat Assessment Team members complete required trainings.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 3/28/2023
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.
Date Issued
|
Report Number
21-00276-67
|
Topics: Suicide Prevention
● Care Coordination
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 6/28/2022
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.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 6/28/2022
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.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 6/28/2022
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.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 6/28/2022
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.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 6/28/2022
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.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 6/28/2022
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.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 6/28/2022
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.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 3/14/2024
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.
Date Issued
|
Report Number
21-00292-73
|
Topics: Care Coordination
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 1/31/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and designates a systems redesign and improvement coordinator.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 1/31/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the Chief of Staff regularly attends Surgical Work Group meetings.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 6/17/2022
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.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 6/17/2022
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.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 4/19/2023
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.
Date Issued
|
Report Number
21-02489-69
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 6/24/2022
The Carl T. Hayden VA Medical Center Director ensures that staff comply with requirements for donning required personal protective equipment prior to entry into decontamination areas.