Recommendations
2204
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 25-01782-158 | Review of the Major Construction Project for the New VA Medical Center in Louisville, Kentucky | Review | ||
1 Establish mechanisms to make sure business cases are developed, promptly reviewed, and approved as required by the Office of Management and Budget Circular A‑11 and VA Directive 0011.
2 Perform periodic reviews to verify that business cases comply with Office of Management and Budget Circular A‑11 requirements by being updated throughout a project’s life cycle to reflect changes in scope, schedule, and cost, and to verify that if changes exceed 10 percent of the initially approved business case, they are reported to the Office of Management and Budget.
3 Verify that milestones for the Louisville new medical center project are updated to incorporate critical user-requested changes and that these changes are completed in a timely manner to prevent further delays, while keeping the project within its authorized scope, cost, and schedule.
4 Establish controls to ensure the executive director of the Office of Construction and Facilities Management fulfills the responsibilities in VA Directive 0067 to incorporate National Environmental Policy Act analysis early on in all land acquisition, planning, design, and construction projects.
5 Conduct a comprehensive review of major construction project obligations to ensure all costs related to each project, including those recorded in separate funding lines, are included in the total estimated project costs reported to Congress, consistent with 38 U.S.C. § 8120, 31 U.S.C. § 1105, Office of Management and Budget Circular A‑11, and volume 8 of VA Financial Policy.
6 Update the responsibilities section of VA Directive 0067 to reflect the expectation that, before budget authorization, major construction projects must proactively identify advance planning fund requirements to support the initiation of NEPA environmental reviews during project development.
7 Provide the VA Office of Inspector General with an implementation schedule for an acquisition framework to enable monitoring of major construction project performance.
Total Monetary Impact of All Recommendations
Open: $1,172,892,283
Closed: $0
Total: $1,172,892,283
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| 25-03946-211 | Audit of Processing of Community Care Requests for Services | Review | ||
1 Assess options to expand and optimize automation tools, including artificial intelligence–based solutions, for request for services processing to reduce manual steps and promote efficiency.
2 Address system limitations that prevent identification of whether actions specific to requests for services have been taken or are pending, such as the delegated clinician review.
3 Review and update national standard operating procedures for request for services processing to clarify roles and responsibilities, address inappropriate practices, and reduce processing delays.
4 Develop processes or controls to help improve the accuracy and consistency of the use of the actual receipt date as the official date the Veterans Health Administration received the request for services to maintain accurate timeliness tracking.
5 Make sure facilities provide accurate notifications to community providers and notify veterans at key processing stages.
6 Implement mechanisms to provide routine oversight of the request for services process, including assessing data accuracy and the timeliness of request processing, to reinforce accountability and support corrective action.
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| 26-00053-273 | Healthcare Facility Inspection of the VA NY Harbor Healthcare System in New York | Healthcare Facility Inspection | ||
1 The Medical Center Director takes appropriate action so emergency department and dental clinic staff maintain a clean and safe environment and repair or replace damaged items to support effective disinfection, as required by Veterans Health Administration Directive 1608(1), Comprehensive Environment of Care Program.
2 The Medical Center Director takes appropriate action so emergency department staff establish and maintain an environment that protects patients’ privacy, as required by the Joint Commission standard, Rights and Responsibilities of the Individual 01.01.01.
3 The Medical Center Director takes appropriate action so all services develop workflows in accordance with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients, including defining responsibilities of non-provider personnel for communicating test results to patients.
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| 26-00084-274 | Healthcare Facility Inspection of the VA White River Junction Healthcare System in Vermont | Healthcare Facility Inspection | ||
1 The Director installs detectable warning surfaces at all walkways that transition to roadways, in accordance with VA’s PG-18-10, Site Design Manual.
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| 25-03943-269 | Mental Health Inspection of the South Texas Veterans Health Care System in San Antonio | Mental Health Inspection Program | ||
1 The Associate Chief of Staff, Mental Health develops and implements written processes to ensure treatment planning on the inpatient mental health unit aligns with Veterans Health Administration Directive 1160.01, Uniform Mental Health Services in VHA Medical Points of Service requirements.
2 The Associate Chief of Staff, Mental Health requires a minimum of four hours of recovery-oriented, interdisciplinary programming on weekends on the inpatient mental health unit, in alignment with Veterans Health Administration Directive 1160.06(1), Inpatient Mental Health Services.
3 The Facility Director ensures implementation of a recovery-oriented environment on the inpatient mental health unit, consistent with Veterans Health Administration’s Design Guide for Inpatient Mental Health & Residential Rehabilitation Treatment Program Facilities.
4 The Facility Director develops and implements a written standard operating procedure for the use of video monitoring on the inpatient mental health unit, as required by Veterans Health Administration Office of Mental Health Standard Operating Procedure 1160.06.1, “Standard Operating Procedure for Maintaining Safety and Security on Inpatient Mental Health Units under VHA [Veterans Health Administration] Directive 1160.06.”
5 The Chief of Staff ensures that only healthcare staff have access to video monitoring in treatment areas and that video equipment is used for monitoring, not recording, in accordance with Veterans Health Administration Directive 1078, Privacy of Persons Regarding Photographs, Digital Images and Video or Audio Recordings.
6 The Facility Director posts signage to notify veterans of video monitoring on the inpatient mental health unit, as required Veterans Health Administration Directive 1078, Privacy of Persons Regarding Photographs, Digital Images and Video or Audio Recordings.
Closure Date:
7 The Facility Director develops and implements written processes to ensure compliance with state involuntary commitment requirements in Veterans Health Administration Directive 1160.06(1), Inpatient Mental Health Services.
8 The Chief of Staff requires documentation of discussions between the prescriber and veteran on the risks and benefits of newly prescribed medications prior to administrationand develops a plan to monitor for sustained compliance, in accordance with Veterans Health Administration Directive 1004.01(3), Informed Consent for Clinical Treatments and Procedures.
9 The Chief of Staff ensures discharge instructions include appointment locations in easy-to-understand language, consistent with Veterans Health Administration’s “Clinic Profile Management Business Rules.”
Closure Date:
10 The Facility Director requires all Interdisciplinary Safety Inspection Team members attend biannual inspections and record attendance consistent with Veterans Health Administration Directive 1167, Mental Health Environment of Care Checklist for Units Treating Suicidal Patients.
11 The Facility Director directs the Interdisciplinary Safety Inspection Team to provide biannual inspection attendance to the Comprehensive Environment of Care Committee, as required by Veterans Health Administration Directive 1167, Mental Health Environment of Care Checklist for Units Treating Suicidal Patients.
12 The Facility Director ensures staff complete appeals within the required time frame in accordance with Veterans Health Administration Office of Mental Health Standard Operating Procedure 1167.1, “Standard Operating Procedure for Submission of MHEOCC [Mental Health Environment of Care Checklist] Inspections and Appeals Under VHA [Veterans Health Administration] Directive 1167.”
13 The Facility Director directs staff to complete the required Mental Health Environment of Care Checklist training as required by Veterans Health Administration Directive 1167, Mental Health Environment of Care Checklist for Units Treating Suicidal Patients.
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| 25-04267-174 | Inspection of Information Security at the Lovell Federal Healthcare System in Illinois | Information Security Inspection | ||
1 Improve vulnerability management processes so that all vulnerabilities are identified and mitigated; for vulnerabilities that cannot be mitigated by VA deadlines, create plans of action and milestones.
Closure Date:
2 Improve the baseline configuration process to make sure network devices and databases are running authorized software that is configured to approved baselines and free of vulnerabilities.
3 Confirm appropriate network isolation and protections for all medical devices and special‑purpose systems hosted on the Lovell Federal Healthcare System networks.
4 Separate the duties of maintaining physical blank key stock and making keys to improve physical access controls over key inventories.
Closure Date:
5 Improve the process for monitoring and servicing uninterruptible power supplies that support the network infrastructure.
6 Complete the installation of grounding measures for all communications closets.
7 Establish a process to make sure a witness observes the destruction of temporary paper files that contain personally identifiable information and protected health information.
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| 24-03185-148 | Review of Minor Construction and Nonrecurring Maintenance Projects at the Fayetteville VA Medical Center in Arkansas | Review | ||
1 In collaboration with the director of Veterans Integrated Service Network 16, verify engineering staff are complying with Veterans Health Administration policies and guidance associated with architectural and engineering design review and inspection procedures.
Closure Date:
2 Verify that all engineering staff understand and are trained on VA design and physical security requirements related to minor and nonrecurring maintenance construction projects.
3 Verify that engineering staff who develop independent government cost estimates are sufficiently trained on developing a statement of work and how these documents affect the cost estimates.
4 Ensure engineering staff are documenting their review and acceptance of architectural and engineering designs as required by the Federal Acquisition Regulation before the solicitation of construction contracts.
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| 26-00030-213 | Healthcare Facility Inspection of the Salisbury VA Health Care System in North Carolina | Healthcare Facility Inspection | ||
1 The Director takes appropriate actions to maintain a clean environment to reduce the risk of infection, in accordance with Veterans Health Administration Directive 1608(1), Comprehensive Environment of Care Program.
2 The Director takes appropriate actions so staff change privacy curtains to reduce the risk of infection and supervisors monitor compliance, in accordance with the facility’s Infection Prevention and Control Manual.
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| 26-00038-262 | Healthcare Facility Inspection of the VA Tuscaloosa Healthcare System in Alabama | Healthcare Facility Inspection | ||
1
The Director takes appropriate action so staff properly store cleaning supplies and leaders monitor corrective actions for sustained compliance, in accordance with Veterans Health Administration Directive 1131, Management of Infectious Diseases and Infection Prevention and Control Programs.
2 The Director takes appropriate action so staff update the facility policy for communicating test results and develop service-level workflows that describe team members’ roles in the process, as required by Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.
Closure Date:
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| 25-00255-206 | Healthcare Facility Inspection of the VA Philadelphia Healthcare System in Pennsylvania | Healthcare Facility Inspection | ||
1 The Veterans Integrated Service Network Director and facility Director take appropriate action for the surveillance system to be fully operational.
2 The Director takes appropriate actions to secure portable liquid nitrogen tanks and store the tanks according to the National Fire Protection Association’s Compressed Gases and Cryogenic Fluids Code, NFPA 55 requirements.
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15702