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Inspector General Open Recommendations

01/31/2023 - Department of Veterans Affairs Noncompliance with Community Care Referrals for Substance Abuse Residential Treatment at the VA North Texas Health Care System Open Recommendations

05
The Under Secretary for Health strengthens mental health treatment coordinator assignment procedures for patients awaiting mental health residential rehabilitation treatment program admission as warranted.
04
The VA North Texas Health Care System Director makes certain that the Bonham Substance Abuse Residential Rehabilitation Treatment Program procedures are consistent with Veterans Health Administration scheduling requirements, and monitors compliance.
03
The Under Secretary for Health ensures that Veterans Integrated Service Network leaders provide adequate oversight to ensure adherence to the mental health residential rehabilitation treatment program access to care policy as required.
02
The VA North Texas Health Care System Director conducts a comprehensive review of the management of community residential care referrals and takes action as warranted.
01
The VA North Texas Health Care System Director ensures that staff provide alternative treatment options, including community residential care referrals, when Veterans Health Administration admission wait time for substance abuse disorder residential rehabilitation treatment exceeds 30 days, and monitors compliance.

01/26/2023 - Department of Veterans Affairs Mistreatment and Care Concerns for a Patient at the VA Montana Healthcare System in Miles City and Fort Harrison. Open Recommendations

07
The Montana VA Healthcare System Director ensures state licensing board processes related to the mistreatment incidents identified in this report are reviewed, deficiencies identified, and compliance processes completed.
06
The Montana VA Healthcare System Director reviews the patient’s acute care, including actions to address medical recommendations, and takes actions as indicated.
05
The Montana VA Healthcare System Director reviews community living center screening and admission evaluation processes and ensures that the processes, including documentation of admissions decisions, roles, and responsibilities are established to meet the care needs of prospective patients, and are communicated with applicable staff, as needed.
04
The Montana VA Healthcare System Director reviews the physician’s care provided to the identified patient with respect to quality of care, including documenting and reporting status changes and concerns, and takes actions as indicated.
03
The Montana VA Healthcare System Director reviews the nursing care provided to the identified patient with respect to quality of care, including adhering to the patient’s care plan, and reporting and documenting status changes, and takes actions as indicated.
02
The Montana VA Healthcare System Director ensures that the rights of community living center patients to refuse treatments or procedures are acknowledged and documented according to Veterans Health Administration requirements, and staff are educated on and adhere to the rights, as needed.
01
The Rocky Mountain Network Director reviews facility staff’s actions taken in response to the allegations and concerns related to the patients identified in this report to ensure Veterans Health Administration and facility requirements were met including Montana elder abuse reporting requirements, and takes actions, such as reporting, disciplinary actions, peer reviews, and consultation with the Office of General Counsel, as needed.

01/25/2023 - Department of Veterans Affairs Poor Emergency Department Care of a Patient at the Baltimore VA Medical Center in Maryland Open Recommendations

01/25/2023 - Department of Veterans Affairs Poor Emergency Department Care of a Patient at the Baltimore VA Medical Center in Maryland [Report Details] Inspection / Evaluation - Open Recommendations

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