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Inspector General Open Recommendations

09/23/2021 - Department of Veterans Affairs Deficiencies in Mental Health Care and Facility Response to a Patient’s Suicide, VA Portland Health Care System in Oregon and Treatment Program Referral Processes at the VA Palo Alto Health Care System in California [Report Details] Inspection / Evaluation - Open Recommendations

01
The VA Portland Health Care System Director establishes a mental health treatment coordinator policy, consistent with Veterans Health Administration policy, and includes procedures for mental health treatment coordinator assignment.
02
The VA Portland Health Care System Director develops procedures consistent with Veterans Health Administration suicide behavior and overdose report staff-specific guidance and monitors for compliance.
03
The Under Secretary for Health aligns policy and training to reflect staff-specific guidance and requirements for suicide behavior and overdose report procedures and disseminates updated information to medical center leaders.
04
The VA Portland Health Care System Director ensures completion of behavioral health autopsy reports within the Veterans Health Administration required time frame.
05
The Under Secretary for Health clarifies timeframe expectations for notification of Residential Rehabilitation Treatment Programs admission decisions to referring providers and patients, and takes action as warranted.
06
The VA Palo Alto Health Care System Director ensures that Residential Rehabilitation Treatment Program procedures are consistent with Veterans Health Administration requirements, including screening and admission decision timeliness, communication of treatment recommendations to referring provider and patient, and acceptance of patient self-referrals.
07
The VA Palo Alto Health Care System Director makes certain that the VA Palo Alto Health Care System Policy 11K-18-04, Assistance Dog Policy, is consistent with Veterans Health Administration policy.

09/23/2021 - Department of Veterans Affairs Comprehensive Healthcare Inspection of the VA Maine Healthcare System in Augusta [Report Details] Review - Open Recommendations

01
The System Director evaluates and determines any additional reasons for noncompliance and ensures the acting Systems Redesign and Improvement Coordinator participates on the Quality, Safety, Value Board to review program data and information.
02
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain the Peer Review Committee submits quarterly summaries of peer review data for review by the Clinical Executive Board.
03
The System Director evaluates and determines any additional reasons for noncompliance and makes certain that the Surgical Work Group meets monthly and the Chief of Staff attends the meetings.
05
The Chief of Staff and Associate Director for Patient and Nursing Services evaluate and determine any additional reasons for noncompliance and make certain the Interfacility Transfer Committee monitors and evaluates patient transfers.
06
The Chief of Staff and Associate Director for Patient and Nursing Services evaluate and determine any additional reasons for noncompliance and make certain that providers document patients’ informed consent prior to inter-facility transfers.
07
The Chief of Staff and Associate Director for Patient and Nursing Services evaluate and determine any additional reasons for noncompliance and ensure that appropriately privileged providers complete or co-sign the VA Inter-Facility Transfer Form or equivalent note prior to patient transfers.
08
The Chief of Staff and Associate Director for Patient and Nursing Services evaluate and determine any additional reasons for noncompliance and make certain that nurse-to-nurse communication between the sending and receiving facility occurs during the inter-facility transfer process.
09
The Chief of Staff and Associate Director for Patient and Nursing Services evaluate and determine any additional reasons for noncompliance and ensure all required representatives attend Disruptive Behavior Committee meetings.
10
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain the Disruptive Behavior Committee documents patient notification of an Order of Behavioral Restriction, with information regarding the right to appeal, in the Disruptive Behavior Reporting System.
11
The System 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

09/23/2021 - Department of Veterans Affairs Better Oversight of Prosthetic Spending Needed to Reduce Unreasonable Prices Paid to Vendors [Report Details] Audit - Open Recommendations

01
Coordinate with appropriate officials, including the VA Office of General Counsel, and determine if 38 U.S.C. § 1703(i) and other reimbursement practices cited in this report apply to the reimbursement rates medical facilities should pay for prosthetic and orthotic items provided by vendors. If they do apply, develop and issue guidance requiring medical facilities to adhere to them; if they do not apply, develop and issue guidance on steps medical facilities need to take to ensure they purchase prosthetic and orthotic items at reasonable prices.
02
Develop and implement effective procedures to monitor prosthetic spending to make sure medical facilities reimburse vendors at reasonable prices for all prosthetic and orthotic items in accordance with updated pricing policies and processes.
03
Coordinate with appropriate officials such as the Prosthetic and Sensory Aids Service executive director and the executive director, Rehabilitation and Prosthetics Service, to establish a formal oversight structure that defines the roles and responsibilities of those charged with providing oversight of the prosthetics program, rescind handbooks that reflect an outdated oversight structure, and communicate updated oversight expectations to the Veterans Integrated Service Networks to promote consistent program oversight.

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