Recommendations
2118
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 24-01330-29 | Improper Sharing of Sensitive Information on Cloud-Based Collaborative Applications | Review | ||
1 Take corrective actions to ensure that facilities and programs remove unauthorized sensitive information from collaborative application sites.
2 Direct facilities and programs to standardize SharePoint administration, inventory and consolidate their SharePoint sites, and enforce the recommended architecture to better control access and content at the facility or program level.
Closure Date:
3 Implement enforcement mechanisms to ensure that facilities and programs are following standardized processes to secure SharePoint and Teams sites.
Closure Date:
4 Expand roles and responsibilities of facility and program information system security officers and privacy officers to include the routine review of SharePoint and Teams site permissions and content.
5 Implement automated tools and policies, supported with training, to enable the timely and routine detection and correction of improper sharing and unauthorized content throughout VA.
6 Mandate standardized training for SharePoint administrators and owners to clarify and reinforce data security requirements.
Closure Date:
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| 24-00990-99 | Delayed Diagnosis and Treatment for a Patient’s Lung Cancer and Deficiencies in the Lung Cancer Screening Program at the VA Eastern Kansas Healthcare System in Topeka and Leavenworth | Hotline Healthcare Inspection | ||
1 The VA Eastern Kansas Healthcare System Director ensures the chief of primary care reviews, strengthens, and implements system Patient Aligned Care Team processes for tracking and following up on community care consults ordered, particularly diagnostic consults, to verify patients receive care and to review and act upon consult results, as clinically indicated.
Closure Date:
2 The VA Eastern Kansas Healthcare System Director reviews institutional disclosures conducted by the system over the past 12 months, including the patient’s institutional disclosure, and ensures these disclosures fully adhere to Veterans Health Administration Directive 1004.08, Disclosure of Adverse Events to Patients, October 31, 2018, including documenting the details of the adverse event and discussion points of the disclosure, and takes action needed to remediate disclosures that do not meet these standards.
Closure Date:
3 The VA Eastern Kansas Healthcare System Director ensures community care staff make the required three attempts to obtain patients’ community care records within 90 days of completed appointments, and monitors for compliance.
4 The VA Eastern Kansas Healthcare System Director collaborates with the Kansas City VA Medical Center Director to review the frequency and circumstances of community care records being sent to the incorrect VA facility, develops, and implements a process for ensuring community care records are delivered to the correct ordering VA facility, educates staff on the process, and monitors for compliance.
Closure Date:
5 The Under Secretary for Health establishes and monitors compliance with a process that ensures the Veterans Health Administration ordering provider receives urgent non-life-threatening abnormal test results from care obtained in the community, such as the diagnostic positron emission tomography scan results described in this report, within a time frame that allows timely attention and appropriate action to be taken.
Closure Date:
6 The Veterans Integrated Service Network Director, in conjunction with the Veterans Health Administration National Center for Lung Cancer Screening Program Office, evaluates the VA Eastern Kansas Healthcare System’s Lung Cancer Screening Program to ensure operational adherence to the Lung Cancer Screening Program requirements, and takes action as needed.
Closure Date:
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| 24-01153-52 | The PACT Act Has Complicated Determining When Veterans’ Benefits Payments Should Take Effect | Review | ||
1 Create a job aid for claims processors on how to determine the correct effective date for PACT Act–related claims.
Closure Date:
2 Remove the outdated effective date builder from the Veterans Benefits Administration’s internal job aids page.
Closure Date:
3 Continue updating the Veterans Benefits Management System-Rating system’s effective date builder to add functionality that applies liberalizing laws on claims when the Veterans Benefits Administration receives an intent to file.
Closure Date:
4 Update the Veterans Benefits Management System-Rating system’s effective date builder to add functionality that applies liberalizing laws on claims when a veteran’s service connection is based on a toxic exposure risk activity.
Closure Date:
5 Evaluate PACT Act refresher training by monitoring the results to assess the effectiveness of the training.
Closure Date:
6 Correct all processing errors on cases identified by the review team and report the results to the Office of Inspector General.
Total Monetary Impact of All Recommendations
Open: $20,400,000
Closed: $0
Total: $20,400,000
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| 24-02356-58 | A Prohibited Default in the Clinically Indicated Date Field Limited Some Veterans’ Eligibility for Community Care at the Omaha VA Medical Center in Nebraska | Review | ||
1 Issue a memorandum that clarifies that automatically prepopulating the clinically indicated date field of a consult is prohibited (barring officially recognized exceptions) and that it should be entered manually.
Closure Date:
2 Determine whether any administrative action should be taken with respect to the conduct of the medical facility director and the chief of staff of the Omaha VA Medical Center.
Closure Date:
3 Direct the medical facility director to educate and train those involved with consults on the process, including how to customize the clinically indicated date to reflect the date of care agreed to by the provider and the veteran. The training should be mandatory, its contents should comply with national policy, and its frequency should be determined by the medical facility director.
Closure Date:
4 Assess the actions the medical facility has taken to review the consults that were potentially affected by the 29-day default in the clinically indicated date field and ensure veterans received the care they needed.
Closure Date:
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| 24-00595-93 | Healthcare Facility Inspection of the VA Western Colorado Healthcare System in Grand Junction | Healthcare Facility Inspection | ||
1 The OIG recommends executive leaders evaluate the toxic exposure screening process and develop a sustainable action plan to ensure staff complete secondary screenings.
Closure Date:
2 The OIG recommends executive leaders ensure facility staff conduct all required monthly and annual fire extinguisher inspections, document the completion date and results, and report compliance rates to the Comprehensive Environment of Care Committee.
Closure Date:
3 The OIG recommends executive leaders ensure facility staff complete preventive maintenance inspections for all medical equipment.
Closure Date:
4 The OIG recommends executive leaders ensure facility staff develop and implement processes to properly disinfect wheelchairs, remove dust from ceiling vents, and repair walls.
5 The OIG recommends executive leaders ensure facility staff keep clean and dirty equipment and supplies separated in storage areas and ensure staff can access medical equipment when needed.
Closure Date:
6 The OIG recommends executive leaders ensure facility staff use video monitors for patient safety purposes only and limit them to staff directly involved in the patient’s care.
Closure Date:
7 The OIG recommends Veterans Integrated Service Network leaders ensure facility executive leaders provide effective oversight of the environment of care program.
8 The OIG recommends executive leaders ensure quality management staff implement a system-wide process to monitor the effectiveness of patient notification of all urgent, noncritical test results.
Closure Date:
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| 22-02369-48 | Independent Audit Report on a Transportation Company’s Billing Practices Under a VA Healthcare System Contract | Audit | ||
1 Seek the opinion of the Office of General Counsel on whether the identified potential overbillings could or should be recouped.
Total Monetary Impact of All Recommendations
Open: $1,811,694
Closed: $0
Total: $1,811,694
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| 24-00295-49 | VHA Should Improve Monitoring of Underground Storage Tanks to Minimize Environmental and Health Risks at VA Medical Facilities | Audit | ||
1 As a part of the annual certification process of the Capital Asset Inventory, the executive director of the Office of Asset Enterprise Management should provide guidance on underground storage tank entries to ensure these assets are recorded with consistent identifying terminology in asset identification fields and with the appropriate real property predominant use code: code 40, “storage (other than buildings).”
Closure Date:
2 Ensure Veterans Integrated Service Network officials fulfill their oversight responsibilities found in Veterans Health Administration Directive 1811 requiring VA medical facilities maintain a current inventory of underground storage tanks, inclusive of all associated equipment and component levels.
3 Ensure the assistant under secretary for health for support updates the responsibility section in Veterans Health Administration Directive 7707 to ensure that the responsibilities of VA medical facility directors include appropriate designation of staff and training for environmental regulatory requirements.
4 Ensure Veterans Integrated Service Networks are fulfilling responsibilities in Veterans Health Administration Directive 1811 to ensure facility compliance with federal, state, and local codes, laws, and regulations—including monitoring and addressing underground storage tank alarms promptly to confirm a release has not occurred.
5 Ensure Veterans Integrated Service Networks are fulfilling responsibilities in Veterans Health Administration Directive 1811 for work order (unplanned corrective maintenance) tracking from creation through completion in the approved maintenance management system—to include underground storage tank and associated component-level equipment failures or deficiencies identified in regulatory agencies’ inspections.
6 Confirm VA medical facility directors and Veterans Integrated Service Network directors are fulfilling responsibilities in Veterans Health Administration Directive 7707 to ensure regulatory compliance deficiencies are promptly reviewed, corrective actions are developed, and issues are tracked through completion to satisfactorily address environmental compliance.
7 Confirm VA medical facility directors and Veterans Integrated Service Network directors are fulfilling their oversight responsibilities found in Veterans Health Administration Directive 7707 to ensure all required federal, state, and local regulatory agencies’ inspections of underground storage tanks are recorded in the Veterans Health Administration issue brief tracking system.
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| 24-00611-82 | Healthcare Facility Inspection of the VA Memphis Healthcare System in Tennessee | Healthcare Facility Inspection | ||
1 The OIG recommends facility leaders improve crosswalk visibility and monitor pedestrian safety between the parking garage and bed tower entrance until completion.
Closure Date:
2 The OIG recommends facility leaders improve doorway safety at the bed tower entrance by placing sensors on the two power-assisted doors, reactivating the revolving door, and monitoring doorway safety until completion.
Closure Date:
3 The OIG recommends the Director ensures staff monitor the emergency exit near the laboratory to make sure the door remains unlocked and operational.
Closure Date:
4 The OIG recommends the Director assesses the facility’s tactile signs (braille) and auditory cues and implements a plan to address the deficient areas.
Closure Date:
5 The OIG recommends facility leaders evaluate the toxic exposure screening process and implement a plan to ensure staff complete the screenings.
Closure Date:
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| 23-02350-95 | Inadequate Governance Structure and Identification of Chief Mental Health Officers’ Responsibilities | National Healthcare Review | ||
1 The Under Secretary for Health clarifies Veterans Integrated Service Network staffing requirements, including mandatory and discretionary positions.
2 The Under Secretary for Health ensures the use of the standardized Veterans Integrated Service Network core organizational chart to promote clarity of the Chief Mental Health Officer position and reporting structure.
3 The Under Secretary for Health considers standardization of the Veterans Integrated Service Network Chief Mental Health Officer functional statement to reflect role responsibilities.
Closure Date:
4 The Under Secretary for Health ensures the alignment of the Veterans Integrated Service Network Chief Mental Health Officer performance plan with the functional statement.
5 The Under Secretary for Health defines the Veterans Integrated Service Network Chief Mental Health Officer role authority to enhance governance efficiency and effectiveness of mental health services.
Closure Date:
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| 24-03692-76 | Review of VA’s $2.9 Billion Supplemental Funds Request for FY 2024 to Support Veterans’ Benefits Payments | Review | ||
1 Develop comprehensive management controls with clear roles and responsibilities at each level of the Veterans Benefits Administration to ensure effective oversight of mandatory accounts and the timely communication of any potential budgetary shortfalls.
Closure Date:
2 Ensure the Office of Financial Management develops procedures to incorporate all available budgetary resources, as reported on the SF-133s, in its calculations for the status of funds reports for transparent communication to internal and external stakeholders.
Closure Date:
3 Institutionalize monthly fiscal reviews between the Office of Financial Management and program offices to routinely assess performance and cost drivers that may affect the status of available funds.
Closure Date:
4 Institutionalize monthly fiscal reviews between the VA Office of Budget and the Veterans Benefits Administration Office of Financial Management to routinely assess performance and cost drivers that may affect the status of available funds.
Closure Date:
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15259