Open Recommendations

The OIG recommends the DNFSB update the Review Agenda guidance to include a scheduling technique and a timeliness metric.

The OIG recommends the DNFSB develop and implement a Knowledge Management program to systematically record Review Agenda knowledge in a centralized location, to strengthen the overall training program.

The OIG recommends the DNFSB update Instruction-530.1, Execution of Technical Staff Reviews and the associated Operating Procedures to align with the current Review Agenda process and correct the deficiencies noted in the DNFSB’s self-assessment.

The VA New Mexico Healthcare System Director ensures that social work staff are knowledgeable that 10-10EZR forms can be completed at any time to correct a patient’s financial information and documents are not required to verify financial information.

The VA New Mexico Healthcare System Director reviews the ineffective communication, collaboration, and utilization of available sources of information by social work staff and the enrollment and eligibility supervisor and ensures the ongoing assessment of barriers that could affect patients’ care.

The VA New Mexico Healthcare System Director identifies why postsurgical follow-up care was not coordinated for the patient and takes action as warranted.

The VA New Mexico Healthcare System Director educates emergency department providers on the expectation for identifying the eligibility of each patient who requires admission and the need to obtain Chief of Staff approval if an ineligible patient necessitates care at the facility.

The VA New Mexico Healthcare System Director ensures that inpatient providers are aware of the process to obtain Chief of Staff approval for an ineligible patient to continue care at the facility when clinically indicated.

The VA New Mexico Healthcare System Director reviews the process for note retractions and ensures providers and document specialists are trained on the process.

The VA New Mexico Healthcare System Director ensures that inpatient social workers, providers, transfer coordinators, and nurses are aware that ineligible patients can be transferred from the facility and provides education related to the processes required for approval and facilitation of the transfer.

The VA New Mexico Healthcare System Director monitors compliance with the requirement that discharge paperwork is provided to each patient who is discharged.

The VA New Mexico Healthcare System Director ensures that providers communicate relevant information to community healthcare providers as needed to ensure continuity of care.

The VA New Mexico Healthcare System Director evaluates that staff (inpatient social workers, providers, transfer coordinators, nurses, and the nursing officer of the day) are aware that ineligible patients can be transported from the facility and provides education related to the processes required for approval and facilitation of the transport.

The VA New Mexico Healthcare System Director educates staff on steps to take if attempts to escalate concerns to their supervisors are not adequately addressed.

The VA New Mexico Healthcare System Director reviews the facility’s root cause analysis process, ensures that staff directly involved in an adverse event do not participate in root cause analysis of an event, and considers if another root cause analysis should be completed on this event.

The VA New Mexico Healthcare System Director makes certain that leaders are aware when assigned as responsible for root cause analysis action items and adhere to action plan due dates.

The VA New Mexico Healthcare System Director takes action to ensure that leaders understand and effectively utilize high reliability organization principles noted in this report to identify and correct deficiencies.

The VA New Mexico Healthcare System Director monitors the podiatry residency program for compliance with VHA Directive 1400.01 postgraduate year 1 resident supervision requirements.

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.