Care in the Community Inspection of Medical Facilities in VISN 4: VA Healthcare

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Date Issued

Wednesday, July 30, 2025

Submitting OIG

Department of Veterans Affairs OIG

Agencies Reviewed/Investigated

Department of Veterans Affairs

Components

Veterans Health Administration

Report Number

24-00825-176

Report Description

This Office of Inspector General (OIG) Care in the Community healthcare inspection program report describes the results of a focused evaluation of community care processes at eight Veterans Integrated Service Network (VISN) 4: VA Healthcare medical facilities with a community care program.

This evaluation focused on five domains:
•    Leadership and Administration of Community Care
•    Administratively Closed Community Care Consults
•    Community Care Provider Requests for Additional Services
•    Care Coordination Activities for Patients Referred for Community Care
•    Community Urgent Care Coordination and Management

The OIG issued 13 recommendations for VA to correct identified deficiencies in the five domains:
•    Leadership and Administration of Community Care
o    Community care oversight councils
o    Staffing tool reassessments
o    Patient safety events
o    Patient safety trends, lessons learned, and corrective actions
o    Community care document importing
•    Administratively Closed Community Care Consults
o    Community care appointment confirmation
o    Medical documents
•    Community Care Provider Requests for Additional Services
o    Request processing
o    Approval and denial letters for community providers and patients
•    Care Coordination Activities for Patients Referred for Community Care
o    Community Care–Care Coordination Plan note use to document care coordination activities
o    Appointment confirmation
•    Community Urgent Care Coordination and Management
o    Community Care–Urgent Care Record note creation

Report Type

Inspection / Evaluation

Location

Pittsburgh, PA
United States

Number of Recommendations

Questioned Costs

Funds for Better Use

Report updated under NDAA 5274

External Link

https://www.vaoig.gov/reports/care-community-healthcare-inspection/care-communi…

Open Recommendations

This report has 13 open recommendations.

Recommendation Number	Significant Recommendation	Recommended Questioned Costs	Recommended Funds for Better Use
01	No	$0	$0
The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures community care oversight councils function according to their charters and meet the required number of times per fiscal year.
02	No	$0	$0
The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care leaders complete the staffing tool reassessment every 90 days.
03	No	$0	$0
The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff enter patient safety events into the Joint Patient Safety Reporting system.
04	No	$0	$0
The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures patient safety managers or designees brief community care patient safety event trends, lessons learned, and corrective actions at community care oversight council meetings.
05	No	$0	$0
The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures staff import all community care documents into patients’ electronic health records within five business days of receipt.
06	No	$0	$0
The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff confirm patients attended their appointments and attempt to obtain community providers’ medical documents prior to administratively closing consults.
07	No	$0	$0
The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff make two additional attempts to obtain community providers’ medical documents within 90 days of the appointment following administrative closure of non-low-risk consults.
08	No	$0	$0
The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff process community providers’ requests for additional services within three business days of receipt.
09	No	$0	$0
The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff send approval or denial letters to community providers for requests for additional services.
10	No	$0	$0
The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff send approval or denial letters to patients for requests for additional services.
11	No	$0	$0
The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff create and use the Community Care–Care Coordination Plan note in the electronic health record to document all care coordination activities for consults with an assigned level of care coordination other than basic.
12	No	$0	$0
The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff confirm patients attended their scheduled community care appointments and received care.
13	No	$0	$0
The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff create the Community Care–Urgent Care Record note in the electronic health record when they receive urgent care documents.