OIG Seal
Department of Veterans Affairs, Office of Inspector General
Michael J. Missal, Inspector General

Oversight Reports

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

The Under Secretary for Health amends Medical Foster Home policy to include processes for reporting Medical Foster Home revocations to appropriate authorities to ensure current and future resident safety.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

We recommended that the Veterans Integrated Service Network Director ensure that the System Director evaluates the care of the subject patient (Patient 1) and consults with the Office of General Counsel for disclosure to the patient, if appropriate.

No. 2   to Veterans Health Administration (VHA)

We recommended that the Veterans Integrated Service Network Director ensure that the System Director consults with the Office of Human Resources and the Office of General Counsel to determine the appropriate administrative action(s), if any, for Primary Care Provider X and Primary Care Provider X’s supervisors.

No. 3   to Veterans Health Administration (VHA)

We recommended that the System Director ensure that providers notify patients of test values and follow up on clinical laboratory results as required.

No. 4   to Veterans Health Administration (VHA)

We recommended that the System Director ensure that providers accurately document patients’ assessment, diagnosis, and treatment information into the electronic health record.

No. 5   to Veterans Health Administration (VHA)

We recommended that the System Director ensure that consults for VHA and non-VA care are entered and completed within time frames set by Veterans Health Administration.

No. 6   to Veterans Health Administration (VHA)

We recommended that the System Director ensure that employees receive training appropriate for the assigned Workplace Behavioral Risk Assessment risk level.

No. 7   to Veterans Health Administration (VHA)

We recommended that the System Director ensure that Clinic employees are trained in emergency management procedures.

No. 8   to Veterans Health Administration (VHA)

We recommended that the System Director ensure that emergency procedures and contact information are posted and readily available to Clinic employees.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

We recommended that the System Director ensure strengthening of procedures for timely processing of Release of Information requests.

No. 2   to Veterans Health Administration (VHA)

We recommended that the System Director strengthen the process to adequately capture and trend complaints related to Release of Information requests in accordance with Veterans Health Administration policy.

No. 3   to Veterans Health Administration (VHA)

We recommended that the System Director ensure an evaluation of the personnel issues negatively impacting staff retention and hiring in the Release of Information section and take appropriate action.

No. 4   to Veterans Health Administration (VHA)

We recommended that the System Director ensure accurate monitoring of Release of Information staff productivity.

No. 5   to Veterans Health Administration (VHA)

We recommended that the System Director ensure accurate and effective trackingand monitoring processes of Release of Information requests.

No. 6   to Veterans Health Administration (VHA)

We recommended that the System Director ensure consultation with the Office ofHuman Resources and the Office of General Counsel to determine the appropriateadministrative action, if any, for managers’ performance related to implementation ofcorrective action plans in response to privacy violations.

No. 7   to Veterans Health Administration (VHA)

We recommended that the System Director ensure Release of Information standardoperating procedures are established in accordance with VHA policy and implemented consistently.

No. 8   to Veterans Health Administration (VHA)

We recommended that the System Director strengthen working relationships andcommunication processes within the facility Release of Information section andamongst staff and Business Office Service managers.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

We recommended that the Facility Director ensure usage of only approved policiesregarding use of benzodiazepines and facility managers monitor compliance.

No. 1   to Veterans Health Administration (VHA)

We recommended that the Facility Director ensure usage of only approved policiesregarding use of benzodiazepines and facility managers monitor compliance.

No. 2   to Veterans Health Administration (VHA)

We recommended that the Facility Director ensure facility managers revise thepatient complaint policy to include the VHA requirement for a clinical appealsprocess and to educate clinicians about the VHA requirement for clinical appealsand monitor compliance.

No. 2   to Veterans Health Administration (VHA)

We recommended that the Facility Director ensure facility managers revise the patient complaint policy to include the VHA requirement for a clinical appeals process and to educate clinicians about the VHA requirement for clinical appeals and monitor compliance.

No. 3   to Veterans Health Administration (VHA)

We recommended that the Facility Director ensure that the Psychosocial ResidentialRehabilitation Treatment Program committee admission screening process isappropriate and timely and that facility managers monitor compliance.

No. 3   to Veterans Health Administration (VHA)

We recommended that the Facility Director ensure that the Psychosocial Residential Rehabilitation Treatment Program committee admission screening process isappropriate and timely and that facility managers monitor compliance.

No. 4   to Veterans Health Administration (VHA)

We recommended that the Facility Director ensure that mental health cliniciansadminister tuberculosis tests (purified protein derivative) when needed forPsychosocial Residential Rehabilitation Treatment Program admission and thatfacility managers monitor compliance.

No. 4   to Veterans Health Administration (VHA)

We recommended that the Facility Director ensure that mental health cliniciansadminister tuberculosis tests (purified protein derivative) when needed for Psychosocial Residential Rehabilitation Treatment Program admission and thatfacility managers monitor compliance.

No. 5   to Veterans Health Administration (VHA)

We recommended that the Facility Director ensure that Mental Health services areprovided timely for patients designated as high risk for suicide that have beenrecently discharged from community hospitals.

No. 5   to Veterans Health Administration (VHA)

We recommended that the Facility Director ensure that Mental Health services areprovided timely for patients designated as high risk for suicide that have beenrecently discharged from community hospitals.

No. 6   to Veterans Health Administration (VHA)

We recommended that the Facility Director ensure that non-VA care for psychiatricservices is offered to patients who need to be seen sooner than VA appointmentavailability permits.

No. 6   to Veterans Health Administration (VHA)

We recommended that the Facility Director ensure that non-VA care for psychiatricservices is offered to patients who need to be seen sooner than VA appointmentavailability permits.

No. 7   to Veterans Health Administration (VHA)

We recommended that the Facility Director request that the Veterans IntegratedService Network Mental Health Program Manager evaluate facility Mental HealthServices and programs for opportunities for improvement.

No. 7   to Veterans Health Administration (VHA)

We recommended that the Facility Director request that the Veterans IntegratedService Network Mental Health Program Manager evaluate facility Mental HealthServices and programs for opportunities for improvement.

No. 8   to Veterans Health Administration (VHA)

We recommended that the Facility Director ensure that a Mental Health TreatmentCoordinator policy is implemented as required by the Veterans Health Administrationand that all patients receiving mental health services are assigned a Mental HealthTreatment Coordinator.

No. 8   to Veterans Health Administration (VHA)

We recommended that the Facility Director ensure that a Mental Health TreatmentCoordinator policy is implemented as required by the Veterans Health Administrationand that all patients receiving mental health services are assigned a Mental HealthTreatment Coordinator.

No. 9   to Veterans Health Administration (VHA)

We recommended that the Facility Director ensure compliance with medication reconciliation as required by facility policies.

No. 9   to Veterans Health Administration (VHA)

We recommended that the Facility Director ensure compliance with medication reconciliation as required by facility policies.

No. 10   to Veterans Health Administration (VHA)

We recommended that the Facility Director ensure that Suicide Behavior Reports are completed for all patient suicide attempts and that the Patient Safety Manager is added as a signer as required by facility policy.

No. 10   to Veterans Health Administration (VHA)

We recommended that the Facility Director ensure that Suicide Behavior Reports are completed for all patient suicide attempts and that the Patient Safety Manager is added as a signer as required by facility policy.

No. 11   to Veterans Health Administration (VHA)

We recommended that the Facility Director ensure that a peer review screening is completed for patients who have attempted suicide within 30 days of seeing a health care professional as required by facility policy.

No. 11   to Veterans Health Administration (VHA)

We recommended that the Facility Director ensure that a peer review screening is completed for patients who have attempted suicide within 30 days of seeing a health care professional as required by facility policy.

No. 12   to Veterans Health Administration (VHA)

We recommended that the Facility Director initiate an external peer review to determine whether mental health staff appropriately managed the patient’s bipolar illness. Based on the results of that peer review, the Facility Director should consult with the Office of Chief Counsel regarding an institutional disclosure, if appropriate.

No. 12   to Veterans Health Administration (VHA)

We recommended that the Facility Director initiate an external peer review to determine whether mental health staff appropriately managed the patient’s bipolar illness. Based on the results of that peer review, the Facility Director should consult with the Office of Chief Counsel regarding an institutional disclosure, if appropriate.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

We recommended that the System Director ensure that system primary care providers receive education on Veterans Health Administration cervical cancer screening guidelines and that supervisors monitor compliance.

No. 2   to Veterans Health Administration (VHA)

We recommended that the System Director review and evaluate the routine use of general anesthesia for loop electrosurgical excision procedures conducted in the operating room and take action as appropriate.

No. 3   to Veterans Health Administration (VHA)

We recommended that the System Director utilize Veterans Health Administration resources to promote a culture that discourages behaviors that undermine safe patient care and effective communication and collaboration between providers and between providers and patients.

No. 4   to Veterans Health Administration (VHA)

We recommended that the System Director ensure that care coordination agreements between primary care and gynecology services meet system annual review requirements.

No. 5   to Veterans Health Administration (VHA)

We recommended that the System Director ensure that Patient Advocacy Program managers enter all complaints into the Patient Advocacy Tracking System database and track all reported complaints to resolution.

No. 6   to Veterans Health Administration (VHA)

We recommended that the System Director ensure that system gynecologists have current privileges that meet Veterans Health Administration and system policy requirements.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

We recommended that the System Director ensure that providers who prescribe methadone receive education on VA/DoD Clinical Practice Guideline recommendations related to the use of methadone for the management of chronic pain.

No. 2   to Veterans Health Administration (VHA)

We recommended that the System Director develop a process to ensure that providers consider VA/DoD Clinical Practice Guideline recommendations, specifically the use of electrocardiograms, in their clinical decision to prescribe methadone for chronic pain management.

No. 3   to Veterans Health Administration (VHA)

We recommended that the System Director ensure that patients receiving methadone be informed, not only of complications related to opioids but also, complications specific to methadone and that this discussion is documented.

No. 4   to Veterans Health Administration (VHA)

We recommended that the System Director ensure that the consent form for patients receiving methadone for chronic pain management be modified to include methadone-specific risks.

No. 5   to Veterans Health Administration (VHA)

We recommended that the System Director confer with the Office of Chief Counsel regarding the patient described in this report for possible institutional disclosure to the designated family member(s), and take action as appropriate.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

We recommended that the Veterans Integrated Service Network Director ensure that Atlantic County Community Based Outpatient Clinic schedulers determine and document appointment dates using clinically indicated and desired/preferred dates and facility managers monitor compliance.

No. 2   to Veterans Health Administration (VHA)

We recommended that the Veterans Integrated Service Network Director ensure Atlantic County Community Based Outpatient Clinic managers implement a process for management of established mental health patients seeking an unscheduled appointment that includes communication between patients and clinical and administrative staff.

No. 3   to Veterans Health Administration (VHA)

We recommended that the Veterans Integrated Service Network Director ensure Atlantic County Community Based Outpatient Clinic managers implement a process including a definition of supervisor responsibilities for oversight and auditing of scheduling and no-shows, and facility managers monitor compliance.

No. 4   to Veterans Health Administration (VHA)

We recommended that the Veterans Integrated Service Network Director ensure Atlantic County Community Based Outpatient Clinic managers implement a process to manage patients who still need care when Community Based Outpatient Clinic staff have cancelled appointments, and facility managers monitor compliance.

No. 5   to Veterans Health Administration (VHA)

We recommended that the Veterans Integrated Service Network Director ensure Atlantic County Community Based Outpatient Clinic managers implement the Community Based Outpatient Clinic Mental Health services termination process as outlined in local policy.

No. 6   to Veterans Health Administration (VHA)

We recommended that the Veterans Integrated Service Network Director ensure the Facility Director implements oversight processes that ensure non-VA care coordination staff follow-up on all consults in a timely manner and facility managers monitor compliance.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

We recommended that the Veterans Integrated Service Network Director ensures that the System Director requires staff to immediately verify resuscitation status without delaying resuscitative efforts.

No. 2   to Veterans Health Administration (VHA)

We recommended that the Veterans Integrated Service Network Director ensures that the System Director requires that System managers update the Cardiopulmonary Resuscitation and Do Not Attempt Resuscitation policies to align with one another and include specific processes and responsibilities for determining resuscitation status, including at the time of a Nurse Led Rapid Response.

No. 3   to Veterans Health Administration (VHA)

We recommended that the Veterans Integrated Service Network Director ensures that the System Director requires that System managers educate staff on telemetry policy, align clinical practice with policy, educate staff on this policy and practice, and monitor compliance.

No. 4   to Veterans Health Administration (VHA)

We recommended that the Veterans Integrated Service Network Director ensures that the System Director requires that System managers obtain an independent external review of this patient’s medical care.

No. 5   to Veterans Health Administration (VHA)

We recommended that the Veterans Integrated Service Network Director ensures that the System Director consider taking appropriate administrative action for all involved clinicians, including consideration of the reporting requirements to applicable state licensing board(s).

No. 6   to Veterans Health Administration (VHA)

We recommended that the Veterans Integrated Service Network Director ensures that the System Director requires that System managers review electronic health record documentation of resident supervision, medical decision-making, and resident physician to attending physician discussion of care during an emergency situation and monitor compliance.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

We recommended that the Veterans Integrated Service Network Director ensure that System leaders establish written protocols to identify a process to transfer Emergency Department boarded patients to available VA and non-VA facilities when acute inpatient beds are unavailable.

No. 2   to Veterans Health Administration (VHA)

We recommended that the Veterans Integrated Service Network Director ensure that the policy that designates the location for Emergency Department patient overflow includes criteria for boarded patients who can be placed in the community living center.

No. 3   to Veterans Health Administration (VHA)

We recommended that the Veterans Integrated Service Network Director ensure that a policy is developed and implemented to ensure that Emergency Department staff offer boarded patients transfer to a VA or non-VA facility for inpatient care and that Emergency Department staff document the offers and managers monitor compliance.

No. 4   to Veterans Health Administration (VHA)

We recommended that the Veterans Integrated Service Network Director ensure that managers continue to strengthen processes to improve boarded patients’ length of stay in the Emergency Department.

No. 5   to Veterans Health Administration (VHA)

We recommended that the Veterans Integrated Service Network Director ensure that Emergency Department providers reassess patients prior to transfer to confirm that patients are stabilized and suitable for transfer to the receiving unit.

No. 6   to Veterans Health Administration (VHA)

We recommended that the Veterans Integrated Service Network Director implement applicable recommendations from previous patient event-related reviews and monitor compliance.

No. 7   to Veterans Health Administration (VHA)

We recommended that the Veterans Integrated Service Network Director consult with the Office of Chief Counsel regarding whether an institutional disclosure might be appropriate.

No. 8   to Veterans Health Administration (VHA)

We recommended that the Veterans Integrated Service Network Director consider requesting an external administrative review to determine whether the system was adequately prepared to safely manage its patient volume.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

We recommended that the Veterans Integrated Service Network Director review the former Chief of Surgery’s performance in relation to issues discussed in this report, and confer with appropriate VA offices to determine the need for administrative action, if any.

No. 2   to Veterans Health Administration (VHA)

We recommended the System Director consult with the National Center for Organizational Development to facilitate organizational improvement following leadership changes and extensive inspections and investigations.

No. 3   to Veterans Health Administration (VHA)

We recommended that the System Director ensure use of the correct methodology to determine the severity assessment code for all reported patient safety events.

No. 4   to Veterans Health Administration (VHA)

We recommended that the System Director ensure compliance with the National Center for Patient Safety’s guidelines on initiation and completion of Root Cause Analysis.

No. 5   to Veterans Health Administration (VHA)

We recommended that the System Director ensure that peer reviews are appropriately completed and address all relevant aspects of care provided by the reviewed clinician.

No. 6   to Veterans Health Administration (VHA)

We recommended that the System Director ensure a process is in place to identify and review cases where institutional disclosure may be indicated, and complete as appropriate.

No. 7   to Veterans Health Administration (VHA)

We recommended the System Director ensure that the Quality, Safety and Value committee minutes include evidence of robust data analysis and action tracking to address performance deficiencies, and monitor for compliance.

No. 8   to Veterans Health Administration (VHA)

We recommended that the System Director ensure adherence to all Veterans Health Administration peer review committee requirements, and monitor for compliance.

No. 9   to Veterans Health Administration (VHA)

We recommended that the System Director ensure that professional practice evaluations include performance data to support provider privileges and are conducted in accordance with Veterans Health Administration and System policy.

No. 10   to Veterans Health Administration (VHA)

We recommended that the System Director evaluate the current System policy and services provided by low volume/no volume providers to determine whether the System should continue to provide those services or seek community alternatives.

No. 11   to Veterans Health Administration (VHA)

We recommended that the System Director require service chiefs to assure that all providers within their purview secure and maintain appropriate computer access to ensure quality and continuity of patient care.

No. 12   to Veterans Health Administration (VHA)

We recommended that the System Director ensure availability of functional equipment, adequate staffing, and enhanced access for personal identity verification card completion.

No. 13   to Veterans Health Administration (VHA)

We recommended that the System Director ensure compliance in monitoring of resident supervision documentation in accordance with Veterans Health Administration and System policies, and take appropriate action when deficiencies are identified.

No. 14   to Veterans Health Administration (VHA)

We recommended that the System Director review letters of agreement between the University of Oklahoma’s surgical residency program and the System to ensure compliance with Accreditation Council for Graduate Medical Education requirements.

No. 15   to Veterans Health Administration (VHA)

We recommended that the System Director continue efforts to recruit and hire for vacancies, and ensure that, until optimal staffing is attained, alternate methods are consistently available to meet patient care needs.

No. 16   to Veterans Health Administration (VHA)

We recommended that the System Director ensure timely completion of specialty care consults and monitor compliance.

No. 17   to Veterans Health Administration (VHA)

We recommended that the System Director implement a process to conduct routine scheduling audits to monitor compliance and identify ongoing training opportunities for all schedulers.

No. 18   to Veterans Health Administration (VHA)

We recommended that the System Director conduct an evaluation of the potential improper payments resulting from clinic cancellations, take appropriate corrective actions, and establish policies to mitigate improper payments related to clinic cancellations from occurring in the future.

No. 19   to Veterans Health Administration (VHA)

We recommended that the System Director continue efforts to improve call center timeliness.

No. 20   to Veterans Health Administration (VHA)

We recommended that the System Director continue efforts to improve timeliness of Care in the Community Program consult completion; enhance patient and community provider understanding of Veterans Choice and Non-VA Care Coordination options; and continue to promote communication and coordination with TriWest Healthcare Alliance to assure appropriate, timely care for patients.

No. 21   to Veterans Health Administration (VHA)

We recommended that the System Director ensure Patient Aligned Care Team clinicians follow Veteran Health Administration requirements for patient notification and follow-up of clinically relevant abnormal laboratory results and document the actions in the electronic health record.

No. 22   to Veterans Health Administration (VHA)

We recommended that the System Director monitor consultation completion timeliness and identify process improvements for consults exceeding 30 days.

No. 23   to Veterans Health Administration (VHA)

We recommended that the System Director continue Emergency Department workgroup efforts to improve the timeliness of care, decrease the frequency of diversion status, and enhance customer service in the Emergency Department.

No. 24   to Veterans Health Administration (VHA)

We recommended that the System Director ensure that all patient care areas comply with environment of care requirements and that action plans specifically address deficient areas identified in this report.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

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