Open Recommendations

The VA Western New York Health Care System Executive Director ensures that community living center staff complete behavioral notes and conduct behavioral rounds, consistent with system policies regarding behavioral health and administration of antipsychotic medications, monitors for compliance, and takes action as indicated.

The VA Western New York Health Care System Executive Director evaluates community living center nursing staff compliance with system policies regarding the administration of medications, and nursing documentation related to medication refusals, medical provider notification, and residents’ nutritional intake, and takes action as required.

The VA Western New York Health Care System Executive Director reviews the system policy regarding the use of antipsychotic medications in the community living center and considers aligning system policy with Veterans Health Administration’s dementia system of care recommendation to document risk-benefit discussions for all residents receiving pharmacological interventions for dementia-related behaviors.

The VA Western New York Health Care System Executive Director makes certain community living center staff comply with the system policy on fingerstick blood sugar testing, including documenting results and notification to the resident’s provider, and monitors compliance, taking action as indicated.

The VA Western New York Health Care System Executive Director reviews Batavia community living center laboratory processes and takes action as necessary to ensure timely completion of orders.

The VA Western New York Health Care System Executive Director ensures community living center staff enter joint patient safety reports and disclosures, as Veterans Health Administration guides and requires, and in support of high reliability organization principles, and monitors compliance.

The VA Western New York Health Care System Executive Director makes certain the community living center quality assurance performance improvement procedures adhere to Veterans Health Administration requirements, including the use of data to track effectiveness of quality assurance activities, and supports improvement in community living center nursing care.

The VA Western New York Health Care System Executive Director ensures completion of the chief geriatric physician’s focused professional practice evaluation for cause per Veterans Health Administration requirements.

The VA Western New York Health Care System Executive Director evaluates community living center medical provider staffing to ensure staffing meets patient care needs and takes action as necessary, including continued recruitment to fill vacancies.

The VA Western New York Health Care System Executive Director ensures review of education plans, education needs assessments, and completion of a system dementia education plan as well as initial and ongoing Staff Training in Assisted Living Residences-VA training, as expected, for all community living center nursing staff, and takes action as indicated.

Increase the oversight role of the CPMO to address deficiencies in the execution of SRBs and
provide SRB members an independent avenue to communicate and address issues during and
after the SRBs

Update the SRB Handbook to reflect current policy, processes, and practices

Evaluate whether the preference for using civil servants is necessary for all disciplines. If not
necessary, consider promoting the use of contractors for board membership in disciplines
where the pool of civil servant expertise may be limited

Evaluate the potential for developing a more formalized pipeline and recruitment process for
SRB participants that could include maintaining a skills database of past members

Review existing conflict of interest policy and processes and consider:
a. clarifying terminology and developing definitions to aid Agency personnel in
consistently identifying which affiliation types are included in existing categories and
the review process used for each, and/or
b. expanding the number of affiliation categories to account for, at a minimum,
international partner agencies

Establish a process for verifying that mission directorates are conducting the required conflict
of interest reviews timely and implement record retention policies regarding SRB conflict of
interest review documents

Verify that contracts used to engage SRB members through contractors adhere to the conflict
of interest processes established in the SRB Handbook

Determine whether there is a need for individual mission directorate guidance for SRB
execution or if individualized mission directorate tailoring can be more effectively accomplished
in the ToR. If mission directorate guidance is determined to be needed, update them
accordingly and establish a frequency for their review and updating

Develop a formal, role-based training program with a focus on first time members in SRB roles

Determine the optimal method(s) and frequency required to keep an SRB appropriately
engaged and informed of program and project status between life-cycle reviews and implement
an applicable procedure in the SRB Handbook or other policy or guidance

Identify obstacles that inhibit programs and projects from providing timely information to SRBs
and implement solutions so that timelines agreed to for data deliverables are met

Implement a process for mission directorates to facilitate the collection and sharing of lessons
learned and document that process in the SRB Handbook

We recommend that the Grantee establish policies and procedures for the timely submission of progress reports in accordance with the Uniform Guidance and ARC grant agreement requirements.

Develop and implement a method to identify and report separate quality statistics for the Military Sexual Trauma Operations Center.

Update the existing two-signature review process for claims processors and designated reviewers to include an increased focus on military sexual trauma denials.