Recommendations
2118
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 24-03542-57 | Mental Health Inspection of the VA Tampa Healthcare System in Florida | Mental Health Inspection Program | ||
1 The Facility Director ensures the Mental Health Executive Council includes veteran representation.
2 The Associate Chief of Staff, Mental Health ensures the development and implementation of written processes for staff training, education, and recovery-oriented services.
Closure Date:
3 The Associate Chief of Staff, Mental Health ensures a minimum of four hours of recovery-oriented, interdisciplinary programming on weekends on the inpatient mental health unit.
4 The Facility Director develops and implements written processes to monitor and track compliance with state involuntary commitment requirements.
5 The Chief of Staff ensures discharge instructions for veterans include appointment locations in easy-to-understand language.
Closure Date:
6 The Facility Director directs staff to comply with VA S.A.V.E. training requirements and monitors for compliance.
7 The Facility Director directs inpatient unit staff, volunteers, and Interdisciplinary Safety Inspection Team members to comply with Mental Health Environment of Care Checklist training requirements and monitors for compliance.
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| 25-00200-48 | Healthcare Facility Inspection of the VA Eastern Colorado Health Care System in Aurora | Healthcare Facility Inspection | ||
1 Facility leaders direct staff to conduct a risk assessment on liquid nitrogen storage, to include the small devices stored in examination rooms, and implement changes if needed.
2 Facility leaders determine appropriate supply storage locations and, for any supplies stored outside of the defined locations, implement a process to ensure staff identify and remove expired supplies.
3 Facility leaders ensure staff label opened multidose medications with expiration dates.
4 Facility leaders ensure staff store clean and dirty items separately.
5 The Director ensures staff implement processes to prevent repeat environment of care findings.
6 The OIG recommends facility leaders ensure the facility has a policy for the communication of test results and staff develop service-level workflows that align with VHA requirements.
7 Veterans Integrated Service Network 19 leaders assess the staffing needs for the facility’s radiology service and provide additional resources to ensure services are readily available to patients.
8 Veterans Integrated Service Network 19 leaders evaluate the reasons for delays in uploading images and reporting test results and assist the facility’s community care leaders to mitigate future delays.
9 Executive leaders monitor root cause analysis improvement actions through completion, monitor outcome measures, and ensure staff implement processes to sustain the improvements.
10 Facility leaders attain appropriate primary care staffing and manageable panel sizes to ensure patients have timely access to high-quality care.
Closure Date:
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| 25-00814-62 | Assessment of Cytopathology Processing at the Oklahoma City VA Medical Center in Oklahoma | Hotline Healthcare Inspection | ||
1 The Oklahoma City VA Health Care System Director, with Pathology and Laboratory Medicine Service leaders, conducts a comprehensive review of the quality of care for the four patients identified in this report, including determinations of cytopathology processing delays and assessment of patient harm, and takes action as warranted.
2 The Oklahoma City VA Health Care System Director ensures that routine non-gynecological turnaround time corrective actions are documented and monitored for effectiveness, as required by the Veterans Health Administration.
3 The Oklahoma City VA Health Care System Director conducts a comprehensive review of the quality of care provided by the Chief of Pathology and Laboratory Medicine Service, identifies deficiencies, and takes action as warranted.
4 The Oklahoma City VA Health Care System Director reviews the Pathology and Laboratory Medicine Service event reporting requirements for variance events and ensures completion according to facility policy and Veterans Health Administration requirements.
5 The Oklahoma City VA Health Care System Director, in conjunction with the National Center for Patient Safety, evaluates patient safety event reporting processes within the Pathology and Laboratory Medicine Service, and ensures completion according to Veterans Health Administration requirements.
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| 25-00975-234 | Inspection of Information Security at the VA Spokane Healthcare System in Washington | Information Security Inspection | ||
1 Implement vulnerability management processes to ensure all vulnerabilities are identified and plans of action and milestones are created for vulnerabilities that cannot be mitigated by VA deadlines.
2 Implement a more effective baseline configuration process to ensure network devices and databases are running authorized software that is configured to approved baselines and free of vulnerabilities.
3 Perform a cost-benefit analysis and implement appropriate controls within the federal Electronic Health Record to limit disclosure of veteran personally identifiable information based on job responsibility.
4 Segregate the duties of maintaining key stock and making keys.
5 Place network infrastructure equipment in a communications closet or approved enclosure to restrict access to only authorized personnel.
6 Complete the installation of grounding measures for all telecommunications closets to protect information technology equipment against electromagnetic pulse attack or electrostatic discharge. Ensure the work completed by contractors adheres to the requirements as defined in the work order.
7 Add anti-ram barriers to protect all sides of a fueling station’s fuel tank.
Closure Date:
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| 25-00529-219 | Audit of Integrated Financial and Acquisition Management System Access Controls | Audit | ||
1 Implement a plan with the Office of Acquisition and Logistics Project Management Office to ensure system access is more granular and the intent of the principle of least privilege is met.
2 Ensure all roles and accesses, including those provided by default access, are reviewed and certified periodically as required.
3 Implement a permanent solution to provide supervisors and information owners with visibility of all roles and accesses, including those provided by default access, granted to users.
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| 25-00214-61 | Healthcare Facility Inspection of the VA Central California Health Care System in Fresno | Healthcare Facility Inspection | ||
1 The Executive Director ensures staff receive education about badge holders’ responsibilities in preventing unauthorized access to VA facilities and computer systems and safeguarding electronic databases including electronic health care records.
2 The Executive Director ensures signs are present and accurate throughout the facility.
Closure Date:
3 The Executive Director ensures staff maintain privacy curtains, preventive maintenance on medical equipment, and splash resistant bottom shelves on supply carts.
Closure Date:
4 The Executive Director ensures staff monitor patient care areas for expired, damaged, and contaminated medications and remove them as needed.
5 The Executive Director ensures staff store medications in pharmaceutical grade refrigerators.
6 The Executive Director ensures primary care staffing is sufficient for patients to receive appropriate health care.
7 The Executive Director reviews staffing levels for the Housing and Urban Development–Veterans Affairs Supportive Housing program and takes action as needed.
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| 25-00243-56 | Healthcare Facility Inspection of the VA Sierra Nevada Health Care System in Reno | Healthcare Facility Inspection | ||
1 The Medical Center Director ensures staff properly store clean medical equipment.
2 Facility leaders develop written workflows for each service to ensure timely communication of test results to providers and patients.
Closure Date:
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| 25-00238-44 | Healthcare Facility Inspection of the VA Battle Creek Healthcare System in Michigan | Healthcare Facility Inspection | ||
1 The Director ensures staff keep the environment clean and safe.
Closure Date:
2 The Director ensures Healthcare Technology Management Service staff inspect, test, and properly document all medical equipment maintenance per their required schedule.
Closure Date:
3 The Director ensures staff implement processes to prevent repeat environment of care findings identified in this report.
Closure Date:
4 Facility leaders ensure service-level workflows include each staff member’s role in the communication of test results process.
Closure Date:
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| 25-00207-36 | Healthcare Facility Inspection of the VA Indiana Healthcare System in Indianapolis | Healthcare Facility Inspection | ||
1 The Assistant Director ensures staff maintain a consistently clean environment throughout the facility to prevent repeat environment of care findings.
2 Executive leaders review the change in laboratory scheduling practices and minimize its effect on clinic efficiency.
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| 25-00215-32 | Healthcare Facility Inspection of the VA Southern Nevada Healthcare System in North Las Vegas | Healthcare Facility Inspection | ||
1 The Executive Director ensures staff consistently label reusable medical equipment to show it is clean and ready for use.
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