Recommendations
2102
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 16-00104-230 | Combined Assessment Program Review of the Fargo VA Health Care System, Fargo, North Dakota | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility managers ensure competency assessment for employees who prepare compounded sterile products includes gloved fingertip sampling.
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2 We recommended that facility managers ensure all compounded sterile product labels contain the preparer and checker initials and the beyond use date.
Closure Date:
3 We recommended that physicians consistently document discharge progress notes or instructions that include all required elements and that facility managers monitor compliance.
Closure Date:
4 We recommended that employees ask inpatients whether they would like to discuss creating, changing, and/or revoking advance directives and that facility manager’s monitor compliance.
Closure Date:
5 We recommended that the facility ensure new clinical employees complete suicide risk management training within the required timeframe and that facility managers monitor compliance.
Closure Date:
6 We recommended that clinicians include documentation of assessment of available lethal means and how to keep the environment safe in Suicide Prevention Safety Plans and that facility managers monitor compliance.
Closure Date:
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| 15-01227-129 | Audit of VA's Conference Management for Fiscal Year 2014 | Audit | ||
1 We recommended the Interim Assistant Secretary for Management update existing guidance to address if and when a Conference Package may be used to summarize the budgets for multiple events and how to present the budget for each event to ensure adequate line item detail for each event.
Closure Date:
2 We recommended the Interim Assistant Secretary for Management update existing guidance to address how to present line item detail of expenditures in the Final Conference Reports if the approved Conference Package was for multiple events to ensure traceability to source documents.
Closure Date:
3 We recommended the Interim Assistant Secretary for Management establish review procedures that ensure Conference Packages and Final Conference Reports comply with law and VA policy and report the results to the Deputy Secretary or VA Chief of Staff.
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4 We recommended the Interim Assistant Secretary for Management update existing policy to provide adequate accountability to ensure that VA organizations comply with conference policies.
Closure Date:
5 We recommended the Interim Assistant Secretary for Management update existing policy to reinstate the Conference Certifying Official as the reviewer of the Conference Package instead of the Responsible Conference Executive.
Closure Date:
6 We recommended the Interim Assistant Secretary for Management update existing policy to reinstate the Corporate Travel Reporting Office review of Conference Packages with a budget of $100,000 or more before submitting the package for Deputy Secretary or Secretary approval.
Closure Date:
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| 14-04897-221 | Healthcare Inspection – Quality of Mental Health Care Concerns, VA Long Beach Healthcare System, Long Beach, California | Hotline Healthcare Inspection | ||
1 We recommended that the System Director ensure that primary care providers follow established guidelines for referral of patients with chronic pain as required by VA policy.
Closure Date:
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| 16-00106-211 | Combined Assessment Program Review of the Charlie Norwood VA Medical Center, Augusta, Georgia | Comprehensive Healthcare Inspection Program | ||
1 We recommended that Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and that facility managers monitor compliance.
2 We recommended that the Patient Safety Manager consistently enter all reported patient incidents into the WEBSPOT database and that facility managers monitor compliance.
3 We recommended that facility managers ensure the availability of personal protective equipment masks in all patient care areas and monitor compliance.
4 We recommended that employees secure medication carts when not in use, remove expired medications from patient care areas, and date multi-dose vials when opened and that facility managers monitor compliance.
5 We recommended that facility managers ensure the inpatient pharmacy has sterile chemotherapy-type gloves available for compounding hazardous medications and monitor compliance.
6 We recommended that a medical physicist complete and document inspections of computed tomography scanners following repair or modifications affecting dose or image quality and that facility managers monitor compliance.
7 We recommended that the facility ensure new clinical employees complete suicide risk management training within the required timeframe and that facility managers monitor compliance.
Closure Date:
8 We recommended that the Suicide Prevention Coordinator consistently provide at least five community outreach activities every month and that facility managers monitor compliance.
9 We recommended that clinicians develop Suicide Prevention Safety Plans during the admission for all patients identified as high risk and that facility managers monitor compliance.
10 We recommended that treatment teams follow up with patients at least four times during the first 30 days after discharge and that facility managers monitor compliance.
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| 16-00007-206 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of James A. Haley Veterans’ Hospital, Tampa, Florida | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers monitor hand hygiene compliance at the 46th Street VA Mental Health and Eye Clinics.
Closure Date:
2 We recommended that the Facility Director ensures the development and implementation of a policy for the management of clinical and mental health emergencies at the 46th Street South VA Eye Clinic.
Closure Date:
3 We recommended that the Facility Director ensures documentation of a Hazard Vulnerability Assessment to identify potential emergencies at the Forty Sixth Street South VA Mental Health Clinic.
Closure Date:
4 We recommended that clinic managers ensure that sterile commercial supplies at the 46th Street South VA Eye Clinic are not expired.
Closure Date:
5 We recommended that clinic managers review the Forty Sixth Street South VA Mental Health Clinic’s hazardous materials inventory twice within a 12-month period.
Closure Date:
6 We recommended that clinic managers provide feminine hygiene disposal bins in women’s public restrooms at the 46th Street South VA Mental Health Clinic.
Closure Date:
7 We recommended that clinic managers at the 46th Street South VA Mental Health and Eye Clinics ensure the information technology server closet is maintained according to information technology safety and security standards.
Closure Date:
8 We recommended that providers sign Home Telehealth assessments and treatment plans.
Closure Date:
9 We recommended that clinicians consistently notify patients of their laboratory results within the timeframe set by local policy.
Closure Date:
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| 15-04709-208 | Combined Assessment Program Review of the James A. Haley Veterans’ Hospital, Tampa, Florida | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility clinical managers consistently review Ongoing Professional Practice Evaluation data every 6 months and that facility managers monitor compliance.
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2 We recommended that facility managers ensure damaged equipment in patient care areas is repaired or removed from service and stained/missing ceiling tiles are replaced.
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3 We recommended that clinicians validate patient and/or caregiver understanding of the discharge instructions provided.
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4 We recommended that the Radiation Safety Officer ensure all computed tomography technologists have documented training on safe procedures for operating the types of computed tomography equipment they use.
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5 We recommended that the facility ensure new employees complete suicide prevention training and new clinical employees complete suicide risk management training within the required timeframe and that facility managers monitor compliance.
Closure Date:
6 We recommended that clinicians ensure patients and/or caregivers receive a copy of the Suicide Prevention Safety Plan and that facility managers monitor compliance.
Closure Date:
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| 15-01957-100 | VA’s Federal Information Security Modernization Act Audit for Fiscal Year 2015 | Audit | ||
1 We recommended the Assistant Secretary for Information and Technology fully implement an agency-wide risk management governance structure, along with mechanisms to identify, monitor, and manage risks across the enterprise. (This is a modified repeat recommendation from prior years.)
Closure Date:
2 We recommended the Assistant Secretary for Information and Technology formally authorize Health Eligibility Center systems to operate in accordance with VA information security standards. (This is a new recommendation.)
Closure Date:
3 We recommended the Assistant Secretary for Information and Technology implement clear roles, responsibilities, and accountability for developing, maintaining, completing, and reporting Plans of Action and Milestones. (This is a repeat recommendation from prior years.)
Closure Date:
4 We recommended the Assistant Secretary for Information and Technology implement mechanisms to ensure Plans of Action and Milestones are updated to accurately reflect current status information. (This is a repeat recommendation from prior years.)
Closure Date:
5 We recommended the Assistant Secretary for Information and Technology implement mechanisms to ensure sufficient supporting documentation is captured in the central Governance Risk and Compliance tool to justify closure of Plans of Action and Milestones. (This is a repeat recommendation from last year.)
Closure Date:
6 We recommended the Assistant Secretary for Information and Technology implement improved processes to ensure that all identified weakness are incorporated into Governance Risk and Compliance tool, in a timely manner, and corresponding POA&Ms are developed to track corrective actions and remediation. (This is a new recommendation.)
Closure Date:
7 We recommended the Assistant Secretary for Information and Technology implement system enhancements to the Governance Risk and Compliance tool to prevent the automatic re-opening of closed Plans of Action and Milestones and update Enterprise Operation¿s version of the tool to reflect NIST 800-53 Revision 4 controls. (This is a new recommendation.)
Closure Date:
8 We recommended the Assistant Secretary for Information and Technology develop mechanisms to ensure system security plans reflect current operational environments, including accurate system interconnections, boundary, control, and ownership information. (This is a repeat recommendation from last year.)
Closure Date:
9 We recommended the Assistant Secretary for Information and Technology implement improved processes for reviewing and updating key security documents such as risk assessments, privacy impact assessments, and security control assessments on an annual basis and ensure all required information accurately reflects the current environment. (This is a repeat recommendation from last year.)
Closure Date:
10 We recommended the Assistant Secretary for Information and Technology implement mechanisms to enforce VA password policies and standards on all operating systems, databases, applications, and network devices. (This is a repeat recommendation from prior years.)
Closure Date:
11 We recommended the Assistant Secretary for Information and Technology implement periodic access reviews to minimize access by system users with incompatible roles, permissions in excess of required functional responsibilities, and unauthorized accounts. (This is a repeat recommendation from prior years.)
Closure Date:
12 We recommended the Assistant Secretary for Information and Technology enable system audit logs and conduct centralized reviews of security violations on mission-critical systems. (This is a repeat recommendation from prior years.)
Closure Date:
13 We recommended the Assistant Secretary for Information and Technology fully implement two-factor authentication for all local and remote access methods throughout the agency. (This is a repeat recommendation from prior years.)
Closure Date:
14 We recommended the Assistant Secretary for Information and Technology implement mechanisms to ensure all remote access computers have updated security patches and antivirus definitions prior to connecting to VA information systems. (This is a repeat recommendation from prior years.)
Closure Date:
15 We recommended the Assistant Secretary for Information and Technology implement more effective automated mechanisms to continuously identify and remedy security deficiencies on VA¿s network infrastructure, database platforms, and Web application servers. (This is a repeat recommendation from last year.)
Closure Date:
16 We recommended the Assistant Secretary for Information and Technology implement a more effective patch and vulnerability management program to address security deficiencies identified during our assessments of VA¿s Web applications, database platforms, network infrastructure, and work stations. (This is a repeat recommendation from last year.)
Closure Date:
17 We recommended the Assistant Secretary for Information and Technology maintain complete and accurate baseline configurations and ensure all baselines are appropriately implemented and checked for compliance with established VA security standards. (This is a modified repeat recommendation from last year.)
Closure Date:
18 We recommended the Assistant Secretary for Information and Technology implement improved network access controls to ensure medical devices and non-OI&T managed networks are appropriately segregated from general networks and mission-critical systems. (This is a repeat recommendation from last year.)
Closure Date:
19 We recommended the Assistant Secretary for Information and Technology consolidate the security responsibilities for non-OI&T networks present under a common control for each site and ensure vulnerabilities are remedied in a timely manner. (This is a modified repeat recommendation from last year.)
Closure Date:
20 We recommended the Assistant Secretary for Information and Technology implement procedures to enforce a standardized system development and change control framework that integrates information security throughout the life cycle of each system. (This is a repeat recommendation from last year.)
Closure Date:
21 We recommended the Assistant Secretary for Information and Technology implement processes to ensure information system contingency plans are updated with the required information. (This is a repeat recommendation from last year.)
Closure Date:
22 We recommended the Assistant Secretary for Information and Technology develop and implement a process for ensuring the encryption of backup data prior to transferring the data offsite for storage. (This is a repeat recommendation from prior years.)
Closure Date:
23 We recommended the Assistant Secretary for Information and Technology implement improved processes for the testing of contingency plans and failover capabilities for major applications and general support systems to ensure that critical components can be recovered at an alternate site in the event of a system failure or disaster. (This is a new recommendation.)
Closure Date:
24 We recommended the Assistant Secretary for Information and Technology perform and document a Business Impact Analysis for all systems and incorporate the results into an overall strategy development effort for contingency planning. (This is a new recommendation.)
Closure Date:
25 We recommended the Assistant Secretary for Information and Technology implement more effective agency-wide incident response procedures to ensure timely resolution of computer security incidents in accordance with VA set standards. (This is a repeat recommendation from prior years.)
Closure Date:
26 We recommended the Assistant Secretary for Information and Technology identify all external network interconnections and implement improved processes for monitoring all VA internal networks, systems, and exchanges for unauthorized activity. (This is a repeat recommendation from last year.)
Closure Date:
27 We recommended the Assistant Secretary for Information and Technology implement improved safeguards to prevent data exfiltration from VA networks. (This is a new recommendation.)
Closure Date:
28 We recommended the Assistant Secretary for Information and Technology fully develop a comprehensive list of approved and unapproved software and implement continuous monitoring processes to identify and prevent the use of unauthorized software on agency devices. (This is a repeat recommendation from prior years.)
Closure Date:
29 We recommended the Assistant Secretary for Information and Technology develop a comprehensive software inventory process to identify major and minor software applications used to support VA programs and operations. (This is a repeat recommendation from prior years.)
Closure Date:
30 We recommended the Assistant Secretary for Information and Technology implement procedures for overseeing contractor-managed cloud-based systems and ensuring information security controls adequately protect VA sensitive systems and data. (This is a repeat recommendation from last year.)
Closure Date:
31 We recommended the Assistant Secretary for Information and Technology implement mechanisms for updating the Federal Information Security Modernization Act systems inventory, including contractor-managed systems and interfaces, and annually review the systems inventory for accuracy. (This is a repeat recommendation from last year.)
Closure Date:
32 We recommended the Assistant Secretary for Information and Technology update all applicable position descriptions to better describe position sensitivity levels, and improve documentation of personnel records of ¿Rules of Behavior¿ and annual privacy training certifications.
Closure Date:
33 We recommended the Assistant Secretary for Information and Technology ensure appropriate levels of background investigations be completed for all personnel in a timely manner, implement processes to monitor and ensure timely reinvestigations on all applicable employees and contractors, and monitor the status of the requested investigations.
Closure Date:
34 We recommended the Assistant Secretary for Information and Technology reduce wireless security vulnerabilities by ensuring sites have up-to-date mechanisms to protect against interception of wireless signals and unauthorized access to the network, and ensure the wireless network is segmented from the general network.
Closure Date:
35 We recommended the Assistant Secretary for Information and Technology identify and deploy solutions to encrypt sensitive data and resolve clear text protocol vulnerabilities.
Closure Date:
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| 16-00103-160 | Combined Assessment Program Review of the VA Manila Outpatient Clinic, Manila, Philippines | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility clinical managers consistently review Ongoing Professional Practice Evaluation data every 6 months and that facility managers monitor compliance.
Closure Date:
2 We recommended that Infection ControlCommittee meeting minutes consistently reflect discussion of identified high-risk areas and include actions to address those areas.
Closure Date:
3 We recommended that facility managers ensure completion of drug destructions at least quarterly.
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4 We recommended that clinicians consistently document that patients are at high risk prior to placing flags in the electronic health records and that facility managers monitor compliance.
Closure Date:
5 We recommended that clinicians include the identification of contact numbers of family or friends for support in Suicide Prevention Safety Plans and that facility managers monitor compliance.
Closure Date:
6 We recommended that facility employees provide education and counseling about adverse consequences of heavy drinking to patients with positive alcohol screens and alcohol consumption above National Institute on Alcohol Abuse and Alcoholism guidelines.
Closure Date:
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| 15-05160-161 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Northern Arizona VA Health Care System, Prescott, Arizona | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers monitor hand hygiene compliance at the Chinle VA Clinic.
Closure Date:
2 We recommended that the managers develop and implement a policy/procedure for the life safety elements at the Chinle VA Clinic.
Closure Date:
3 We recommended that managers develop and implement a policy that requires the Chinle VA Clinic staff to receive regular information on their responsibilities in emergency response operations.
Closure Date:
4 We recommended that managers ensure that Chinle VA Clinic staff participate in emergency management exercises.
Closure Date:
5 We recommended that managers ensure walls in patient care areas at the Chinle VA Clinic are repaired.
Closure Date:
6 We recommended that managers ensure that the Chinle VA Clinic has functional and accessible hand hygiene facilities.
Closure Date:
7 We recommended that managers at the Chinle VA Clinic ensure food and drink are not kept in refrigerators or freezers in patient care areas.
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8 We recommended that managers control access to and from areas identified as security sensitive at the Chinle VA Clinic.
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9 We recommended that managers review the Chinle VA Clinic’s hazardous materials inventory twice within a 12-month period.
Closure Date:
10 We recommended that managers equip examination room doors with electronic or manual locks at the Chinle VA Clinic.
Closure Date:
11 We recommended that managers provide feminine hygiene products and disposal bins in women’s public restrooms at the Chinle VA Clinic.
Closure Date:
12 We recommended that managers at the Chinle VA Clinic ensure the information technology server closet is maintained according to information technology safety and security standards.
Closure Date:
13 We recommended that providers sign Home Telehealth assessments and treatment plans.
Closure Date:
14 We recommended that clinicians document the Home Telehealth enrollment process prior to the entry of monthly monitoring notes.
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15 We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA policy.
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16 We recommended that acceptable providers perform and document suicide risk assessments for all patients with positive PTSD screens.
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17 We recommended that further diagnostic evaluations are offered to patients with positive PTSD screens.
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18 We recommended that providers complete diagnostic evaluations for patients with positive PTSD screens.
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| 14-02384-45 | Follow-Up Audit of VBA's Internal Controls Over Disability Benefits Questionnaires | Audit | ||
1 We recommended the Acting Under Secretary for Benefits evaluate options for electronically capturing and analyzing information contained on completed Disability Benefits Questionnaires and implement the most cost effective option. (Similar to recommendation from 2012 Office of Inspector General audit report)
Closure Date:
2 We recommended the Acting Under Secretary for Benefits revise the remaining 59 public-use Disability Benefits Questionnaires to provide veterans and clinicians adequate notification regarding verification of submitted information.
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3 We recommended the Acting Under Secretary for Benefits establish policies and procedures for determining if clinicians who prepare public-use Disability Benefits Questionnaires are private or Veterans Health Administration clinicians.
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4 We recommended the Acting Under Secretary for Benefits revise policies and procedures to include steps for obtaining missing public-use Disability Benefits Questionnaires clinician information and verifying clinicians have an active medical license. (Similar to recommendation from 2012 Office of Inspector General audit report)
Closure Date:
5 We recommended the Acting Under Secretary for Benefits revise Veterans Affairs Regional Office quality assurance review methodologies to review appropriate samples of claims including public-use Disability Benefits Questionnaires.
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6 We recommended the Acting Under Secretary for Benefits revise local quality assurance reviews to evaluate Veterans Affairs Regional Office compliance with Disability Benefits Questionnaires’ special-issue indicator requirements.
7 We recommended the Acting Under Secretary for Benefits revise local quality assurance reviews to evaluate Veterans Affairs Regional Office compliance with public-use Disability Benefits Questionnaires’ clinician information completeness requirements.
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8 We recommended the Acting Under Secretary for Benefits establish procedures requiring Compensation Service Disability Examination Management staff to analyze local quality assurance review results to identify systemic issues related to compliance with Disability Benefits Questionnaires’ special-issue indicator and clinician information completeness requirements.
Closure Date:
9 We recommended the Acting Under Secretary for Benefits establish procedures requiring Veterans Affairs Regional Office staff to receive recurring training on systemic issues identified during analyses of local quality assurance review results related to compliance with Disability Benefits Questionnaires’ special-issue indicator and clinician information completeness requirements.
Closure Date:
10 We recommended the Acting Under Secretary for Benefits require Veterans Benefits Administration’s Compensation Service Disability Examination Management staff to conduct annual validation reviews that select samples from a complete universe of claims with public-use Disability Benefits Questionnaires and focus on public-use Disability Benefits Questionnaires that pose an increased risk of fraud. (Similar to recommendation from 2012 Office of Inspector General audit report)
Closure Date:
11 We recommended the Acting Under Secretary for Benefits revise policies and procedures to include follow-up actions for inadequate public-use Disability Benefits Questionnaires.
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12 We recommended the Acting Under Secretary for Benefits revise the Systematic Technical Accuracy Review checklists and local quality assurance reviews to evaluate whether claims processors use adequate public-use Disability Benefits Questionnaires instead of obtaining unnecessary Veterans Health Administration compensation and pension examinations.
Closure Date:
13 We recommended the Acting Under Secretary for Benefits establish procedures requiring Compensation Service Disability Examination Management staff to analyze local quality assurance review results to identify systemic issues related to public-use Disability Benefits Questionnaires, including unnecessary Veterans Health Administration compensation and pension examinations.
Closure Date:
14 We recommended the Acting Under Secretary for Benefits establish procedures requiring Veterans Affairs Regional Office staff to receive recurring training on systemic issues identified during analyses of local quality assurance review results related to public-use Disability Benefits Questionnaires, including unnecessary Veterans Health Administration compensation and pension examinations.
Closure Date:
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15160