Recommendations
2103
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 15-05328-373 | Healthcare Inspection – Colorectal Cancer Screening Practices, Charlie Norwood VA Medical Center, Augusta, Georgia | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that the selection of a colorectalcancer screening method is based on a shared decision-making process between apatient and his/her provider and that the patient‘s preference is honored.
Closure Date:
2 We recommended that the Facility Director define and communicate current localprocesses for obtaining screening colonoscopies.
Closure Date:
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| 15-04655-347 | Healthcare Inspection – Summarization of Select Aspects of the VA Pacific Islands Health Care System, Honolulu, Hawaii | Hotline Healthcare Inspection | ||
1 We recommended that the VA Pacific Islands Health Care System Director continue efforts to enhance the availability of, and access to, a comprehensive network of care and services.
Closure Date:
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| 15-03706-330 | Review of the Replacement of the Denver Medical Center, Eastern Colorado Health Care System | Audit | ||
1 We recommended the Principal Executive Director of Office of Acquisition, Logistics, and Construction ensure required reconciliations of cost estimates be performed prior to releasing construction design documents for all major construction projects.
Closure Date:
2 We recommended the Principal Executive Director of Office of Acquisition, Logistics, and Construction provide sufficient, adequately trained and experienced staff to ensure appropriate oversight is provided over all phases for future major construction projects.
Closure Date:
3 We recommended the Principal Executive Director of the Office of Acquisition, Logistics, and Construction establish policies and procedures to ensure disputes are resolved before proceeding with projects when actual cost and schedule milestones exceed established planned thresholds.
Closure Date:
4 We recommended the Principal Executive Director of the Office of Acquisition, Logistics, and Construction implement mechanisms to ensure that adequate acquisition plans for major construction projects are completed at each appropriate acquisition stage.
Closure Date:
5 We recommended the Principal Executive Director of the Office of Acquisition, Logistics, and Construction ensure adequate controls are implemented and monitored to verify change requests are processed timely.
Closure Date:
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| 15-02776-240 | Review of VA’s Alleged Improper Termination of the e Learning Task Order | Audit | ||
1 We recommended the Deputy Assistant Secretary for Acquisition and Logistics implement a mechanism to ensure proper coordination between the Veterans Affairs Acquisition Academy and Office of Logistics and Supply Chain Management when developing logistics training.
Closure Date:
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| 16-00623-306 | Review of Alleged Breach of Privacy and Confidentiality of Personally Identifiable Information at the Milwaukee VARO | Audit | ||
1 We recommended the VA Assistant Secretary for Information and Technology improve VA’s email security filtering software configuration controls to effectively flag improper transmissions of veterans’ personally identifiable information over the VA network.
Closure Date:
2 We recommended the VA Assistant Secretary for Information and Technology establish Memoranda of Understandings with third party organizations that define network responsibilities, processes and procedures for handling sensitive veterans’ information, and require information security controls are implemented commensurate with VA’s information security standards.
Closure Date:
3 We recommended the VA Assistant Secretary for Information and Technology evaluate whether permanent encryption controls are needed for non-VA employees who maintain VA accounts for conducting business on behalf of veterans.
Closure Date:
4 We recommended the VA Assistant Secretary for Information and Technology conduct reviews of processes, procedures, and controls in place at VA regional offices that collaborate with third party organizations to ensure security of sensitive veterans’ information.
Closure Date:
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| 15-03713-288 | Healthcare Inspection – Emergency Department, Mental Health Service, and Suicide Prevention Training Concerns, Mann-Grandstaff VA Medical Center, Spokane, Washington | Hotline Healthcare Inspection | ||
1 We recommended that the Interim Facility Director strengthen processes to ensure suicide prevention training is completed per Veterans Health Administration Directive 1071 and monitor compliance.
Closure Date:
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| 15-01994-238 | Review of Alleged Contractor Information Security Violations in the Alaska VA Healthcare System | Audit | ||
1 We recommended the VA Northwest Health Network management assign a local Contracting Officer¿s Representative and Information Security Officer to provide oversight of Alaska VA Healthcare System contractors.
Closure Date:
2 We recommended the VA Northwest Health Network management, in conjunction with the Assistant Secretary for Information and Technology, ensure that ProCare personnel complete VA's information security awareness training and sign the Contractor Rules of Behavior.
Closure Date:
3 We recommended the Assistant Secretary for Information and Technology conduct a site assessment of information security controls at the ProCare facility, to include a risk assessment to determine the extent that any sensitive veteran data may have been compromised and, if so, with appropriate corrective action, to ensure compliance with VA and Federal information security requirements.
Closure Date:
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| 14-02725-316 | Healthcare Inspection – Administrative Response to Deaths and Quality of Care Irregularities, VA North Texas Health Care System, Dallas, Texas | Hotline Healthcare Inspection | ||
1 We recommended that the System Director ensure that the care of Patient A is evaluated, including a review of computerized tomography scan orders and imaging study results, and take action if appropriate.
Closure Date:
2 We recommended that the System Director consider revising the Do Not Resuscitate Policy to include re-addressing Do Not Resuscitate orders status with patients prior to any procedures in the hospital.
Closure Date:
3 We recommended that the System Director ensure timely compliance with all elements of the Drug-Free Workplace Program.
Closure Date:
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| 14-04505-346 | Healthcare Inspection – Diagnosis and Treatment of a Patient’s Adrenal Insufficiency at a Virginia VA Medical Center | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director initiate a clinical review of this case and take appropriate actions to educate providers, if indicated.
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| 15-02560-365 | Administrative Investigation - Misuse of Official Time, Denver VA Regional Office, Lakewood, CO | Administrative Investigation | ||
1 We recommend that the Director, VBA Continental District, confer with the Offices of General Counsel (OGC), Human Resources (OHR), and Accountability Review to determine the appropriate administrative action to take, if any, against Ms. Murphy.
Closure Date:
2 We recommend that the Director, VBA Continental District, review whether the privilege of credit hours and telework should be revoked and ensure that Ms. Murphy receives refresher training on VA’s policy for time and attendance, credit hours, and telework.
Closure Date:
3 We recommend that the Director, VBA Continental District, confer with OGC and OHR concerning the 14 days in which Ms. Murphy was unable to fully account for her activities, determine whether she was absent without approved leave, and initiate action to recover pay she received when she was not present for duty.
Closure Date:
4 We recommend that the Director, VBA Continental District, ensure that any VARO local policy for credit hours complies with VA policy and that employees use VA Form 5631 or the ETA system as the official means to record, certify, and report their time and attendance, to include any compensatory or credit hours earned or used.
Closure Date:
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15168