Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 22-02961-71 | Inspection of Information Security at the St. Cloud VA Medical Center in Minnesota | Information Security Inspection | ||
1 The assistant secretary for information and technology and chief information officer implement a more effective vulnerability management program to identify all critical security deficiencies on the network and to remediate vulnerabilities within policy timelines.
2 The assistant secretary for information and technology and chief information officer implement a more effective inventory process to identify network devices.
Closure Date:
3 The assistant secretary for information and technology and chief information officer implement processes to prevent the use of prohibited software on agency devices.
Closure Date:
4 The assistant secretary for information and technology and chief information officer test the emergency power bypass during annual uninterruptible power supply testing and document results.
Closure Date:
5 The assistant secretary for information and technology and chief information officer ensure network segmentation controls are applied to all network segments with medical devices and special-purpose systems.
Closure Date:
6 The assistant secretary for information and technology and chief information officer ensure access authorization memorandums are present in all communication rooms.
Closure Date:
7 The assistant secretary for information and technology and chief information officer ensure that physical access for the data center and communication rooms are reviewed on a quarterly basis.
Closure Date:
8 The assistant secretary for information and technology and chief information officer ensure visitor access records are available and reviewed on a quarterly basis.
Closure Date:
9 The St. Cloud VA Medical Center director ensure video surveillance systems are operational and monitored for the data center.
10 The St. Cloud VA Medical Center director ensure communication rooms with infrastructure equipment have adequate environmental controls.
Closure Date:
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| 22-00228-127 | Comprehensive Healthcare Inspection of the Manila VA Clinic in Pasay City, Philippines | Comprehensive Healthcare Inspection Program | ||
1 The Chief Medical Officer evaluates and determines any additional reasons for noncompliance and ensures the Medical Executive Board recommends continuation of privileges based, in part, on Ongoing Professional Practice Evaluation results.
Closure Date:
2 The Chief Medical Officer evaluates and determines any additional reasons for noncompliance and ensures providers complete Comprehensive Suicide Risk Evaluations on the same day as patients’ positive suicide risk screens.
Closure Date:
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| 22-00046-126 | Comprehensive Healthcare Inspection of the New Mexico VA Health Care System in Albuquerque | Comprehensive Healthcare Inspection Program | ||
1 The Executive Director evaluates and determines any additional reasons for noncompliance and ensures the Executive Leadership Board recommends, implements, and monitors improvement actions.
Closure Date:
2 The Executive Director evaluates and determines any additional reasons for noncompliance and ensures the Protected Peer Review Committee recommends improvement actions for Level 3 peer reviews.
Closure Date:
3 The Executive Director evaluates and determines any additional reasons for noncompliance and ensures staff either conduct an individual root cause analysis for all events receiving an actual or potential safety assessment code score of three or include the events in an aggregated review.
Closure Date:
4 The Chief of Staff determines the reasons for noncompliance and ensures providers with similar training and privileges complete licensed independent practitioners’ Focused Professional Practice Evaluations.
Closure Date:
5 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs recommend licensed independent practitioners’ continued privileges based on Ongoing Professional Practice Evaluation activities.
Closure Date:
6 The Assistant Director determines the additional reasons for noncompliance and ensures staff maintain, inspect, and test biomedical equipment according to the manufacturer’s recommendations.
Closure Date:
7 The Associate Director and Associate Director, Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure staff remove supplies from shipping cartons and corrugated boxes prior to putting them in clean storage areas.
Closure Date:
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| 22-02960-70 | Inspection of Information Security at the James E. Van Zandt VA Medical Center in Altoona, Pennsylvania | Information Security Inspection | ||
1 Verify and make necessary corrections to the systems’ component inventory in the VA’s Enterprise Mission Assurance Support Service.
Closure Date:
2 Improve vulnerability management processes to ensure system changes occur within organization timelines.
Closure Date:
3 Develop and approve an authorization to operate for the special-purpose system.
Closure Date:
4 Validate that appropriate physical and environmental security measures are implemented and functioning as intended.
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| 22-00038-125 | Comprehensive Healthcare Inspection of the VA North Texas Health Care System in Dallas | Comprehensive Healthcare Inspection Program | ||
1 The Executive Director evaluates and determines additional reasons for noncompliance and ensures leaders conduct and accurately document institutional disclosures for applicable sentinel events.
Closure Date:
2 The Assistant Director Clinical Services evaluates and determines any additional reasons for noncompliance and ensures mental health staff attempt weekly follow-up until care is established for patients discharged from the emergency department who are at intermediate or high acute or chronic risk of suicide.
Closure Date:
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| 23-00237-124 | Review of VA’s Compliance with the Payment Integrity Information Act for Fiscal Year 2022 | Review | ||
1 The under secretary for benefits reduces improper and unknown payments to below 10 percent for the Pension Program.
Closure Date:
2 The under secretary for health reduces improper and unknown payments to below 10 percent for the Purchased Long-Term Services and Supports Program.
Closure Date:
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| 21-03598-92 | Goals Not Met for Implementation of the Beneficiary Travel Self-Service System | Review | ||
1 Director of the Veterans Transportation Program determines what system changes are needed to meet auto-adjudication goals and implement these changes.
Closure Date:
2 Director of the Veterans Transportation Program conducts outreach to users, solicits feedback, and considers whether system changes are needed based on feedback, to increase self-service portal usage.
Closure Date:
3 Assistant Under Secretary for Health for Operations create an action plan to phase out continued use of the VistA beneficiary travel function.
Closure Date:
4 Assistant Under Secretary for Health for Operations coordinates with the veteran’s health administration office of finance and assess whether duplicate payments were made to veterans requesting travel reimbursement since the new system went live.
Closure Date:
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| 22-00053-116 | Comprehensive Healthcare Inspection of the VA San Diego Healthcare System in California | Comprehensive Healthcare Inspection Program | ||
1 The Director determines the reasons for noncompliance and ensures leaders conduct institutional disclosures for applicable sentinel events.
Closure Date:
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| 21-03233-122 | Vet Center Inspection of North Atlantic District 1 Zone 3 and Selected Vet Centers | Vet Center Inspection Program | ||
1 The District Director determines reasons clinical quality review remediation plans did not include documentation of deficiency resolution and the time frame for resolution for the Center City, Huntington, Northeast, and Scranton Vet Centers; takes indicated actions to ensure completion; and monitors compliance.
Closure Date:
2 The District Director determines reasons for lack of evidence that clinical quality review deficiencies were resolved at the Center City, Huntington, Northeast, and Scranton Vet Centers; takes indicated actions to ensure completion; and monitors compliance.
3 The District Director determines reasons administrative quality review remediation plans were not completed at the Beckley and Bucks County Vet Centers, ensures completion, and monitors compliance.
Closure Date:
4 The District Director determines the reasons administrative quality review remediation plans do not include the Deputy District Director’s approval and date of approval as required, and ensures compliance.
Closure Date:
5 The District Director determines reasons administrative quality review remediation plans did not include documentation of deficiency resolution and the time frame for resolution for the Center City, Huntington, Northeast, and Scranton Vet Centers; takes indicated actions to ensure completion; and monitors compliance.
Closure Date:
6 The District Director determines reasons for lack of evidence for administrative quality review deficiency resolution for the Center City, Huntington, Northeast, and Scranton Vet Centers; takes indicated actions to ensure completion; and monitors compliance.
Closure Date:
7 The District Director ensures completion of a morbidity and mortality review for the death by homicide, and ensures all future morbidity and mortality reviews are completed as required.
Closure Date:
8 The District Director ensures the intake portion of the psychosocial assessment is completed, and monitors compliance across all zone vet centers.
Closure Date:
9 The District Director ensures suicide risk assessments are completed on the first clinical visit, and monitors compliance across all zone vet centers.
Closure Date:
10 The District Director ensures clinical staff consult and coordinate care with the support VA medical facility for shared clients flagged as high risk for suicide, and monitors compliance across all zone vet centers.
Closure Date:
11 The District Director verifies clinical staff follow confidentiality requirements when consulting and coordinating care with the support VA medical facility for shared clients at high risk for suicide, and monitors compliance across all zone vet centers.
12 The District Director confirms clinical staff make timely notification to the suicide prevention coordinator at the support VA medical facility for clients with significant safety risks, and monitors compliance across all zone vet centers.
Closure Date:
13 The District Director ensures clinical staff complete safety plans for clients that are assessed at intermediate or high suicide risk level in either acute, chronic, or both categories as required, and monitors compliance across all zone vet centers.
Closure Date:
14 The District Director ensures clinical staff consult with the vet center director, external clinical consultant, associate district director for counseling, or support VA medical facility mental health provider following a client’s suicide risk assessment as required, and monitors compliance across all zone vet centers.
Closure Date:
15 The District Director, in collaboration with the support VA medical facility clinical or administrative liaisons, determines the reasons for noncompliance with staff participation on the mental health council for the Center City, Huntington, Northeast, and Scranton Vet Centers, and takes actions as indicated to ensure compliance with Readjustment Counseling Service requirements.
Closure Date:
16 The District Director determines the reasons for noncompliance with critical event plans with desktop reference at the Center City and Northeast Philadelphia Vet Centers, and takes actions as indicated to ensure compliance with Readjustment Counseling Service requirements.
Closure Date:
17 The District Director determines reasons for noncompliance with the appointment of a clinical liaison at the Scranton Vet Center, ensures assignment of a mental health professional as liaison, and monitors compliance.
Closure Date:
18 The District Director determines reasons for noncompliance with a process for completing and tracking four hours of external clinical consultation per month at the Center City, Scranton, and Northeast Vet Centers; ensures Vet Center Directors implement processes; and monitors compliance.
Closure Date:
19 The District Director determines reasons for noncompliance with staff supervision provided by vet center directors at the Center City, Huntington, Northeast, and Scranton Vet Centers; ensures staff supervision occurs as required; and monitors compliance.
Closure Date:
20 The District Director verifies and determines reasons for noncompliance with monthly chart audits at the Center City, Huntington, Northeast, and Scranton Vet Centers; ensures chart audits are completed as required; and monitors compliance.
Closure Date:
21 The District Director determines reasons employees at the Center City, Huntington, Northeast, and Scranton Vet Centers did not complete required trainings; ensures all staff complete mandatory trainings; and monitors compliance.
Closure Date:
22 The District Director evaluates and determines reasons for noncompliance with tactile (braille) signage at the Center City, Huntington, and Northeast Vet Centers, and ensures all exit doors are compliant with Architectural Barriers Act Standards.
Closure Date:
23 The District Director reviews reasons for noncompliance with securing confidential and sensitive information at the Center City Vet Center, and ensures all vet center employees safely and securely store protected health information.
Closure Date:
24 The District Director reviews reasons for noncompliance with having a current and comprehensive emergency and crisis plan at the Center City and Northeast Vet Centers, ensures completion of a current and comprehensive emergency and crisis plan, and monitor’s compliance.
Closure Date:
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| 21-03269-123 | Vet Center Inspection of North Atlantic District 1 Zone 4 and Selected Vet Centers | Vet Center Inspection Program | ||
1 The District Director determines reasons clinical quality review remediation plans did not include documentation of deficiency resolution and the time frame for resolution for the Baltimore, Dundalk, Raleigh, and Richmond Vet Centers; takes indicated actions to ensure completion; and monitors compliance.
2 The District Director determines reasons for lack of evidence for clinical quality review deficiency resolution for the Baltimore, Dundalk, Raleigh, and Richmond Vet Centers; takes indicated actions to ensure completion; and monitors compliance.
3 The District Director determines reasons the administrative quality review remediation plan was not completed for one vet center within the zone, ensures completion, and monitors compliance.
Closure Date:
4 The District Director determines reasons administrative quality review remediation plans did not include documentation of deficiency resolution and the time frame of resolution for the Dundalk, Raleigh, and Richmond Vet Centers; takes indicated actions to ensure completion; and monitors compliance.
Closure Date:
5 The District Director determines reasons for lack of evidence for administrative quality review deficiency resolution for the Dundalk, Raleigh, and Richmond Vet Centers; takes indicated actions to ensure completion; and monitors compliance.
Closure Date:
6 The District Director ensures the intake portion of the psychosocial assessment is completed and monitors compliance across all zone vet centers.
Closure Date:
7 The District Director ensures suicide risk assessments are completed on the first clinical visit and monitors compliance across all zone vet centers.
Closure Date:
8 The District Director ensures clinical staff consult and coordinate care with the support VA medical facility for shared clients flagged as high risk for suicide and monitors compliance across all zone vet centers.
9 The District Director verifies clinical staff follow confidentiality requirements when consulting and coordinating care with the support VA medical facility for shared clients at high risk for suicide and monitors compliance across all zone vet centers.
10 The District Director ensures clinical staff complete safety plans for clients that are assessed at intermediate or high suicide risk level in either acute, chronic, or both categories as required; and monitors compliance across all zone vet centers.
Closure Date:
11 The District Director ensures clinical staff consult with the vet center director, external clinical consultant, associate district director for counseling, or support VA medical facility mental health provider following a client’s suicide risk assessment as required; and monitors compliance across all zone vet centers.
Closure Date:
12 The District Director, in collaboration with the support VA medical facility clinical or administrative liaisons, determines the reasons for noncompliance with staff participation on the mental health council for the Baltimore, Dundalk, Raleigh, and Richmond Vet Centers; and takes action as indicated to ensure compliance with Readjustment Counseling Services requirements.
13 The District Director determines reasons for noncompliance with High Risk Suicide Flag SharePoint site requirements and the tracking of continuity of care for clients at risk at the Raleigh Vet Center and takes action to ensure requirements are met, and monitors compliance.
Closure Date:
14 The District Director determines reasons the Raleigh and Richmond Vet Center Directors did not have accurate knowledge of type of clients on the High Risk Suicide Flag SharePoint site, takes actions to ensure vet center directors incorporate relevant information from the SharePoint site to safely disposition clients, and monitors compliance.
Closure Date:
15 The District Director determines the reasons for noncompliance with staff access to critical event plans that included a desktop reference at the Baltimore and Dundalk Vet Centers and takes actions as indicated to ensure compliance with Readjustment Counseling Service requirements.
Closure Date:
16 The District Director determines reasons for noncompliance with a process for completing and tracking four hours of external clinical consultation per month at the Baltimore, Dundalk, and Raleigh Vet Centers; ensures vet center directors implement processes; and monitors compliance.
Closure Date:
17 The District Director determines reasons for noncompliance with staff supervision provided by vet center directors at the Baltimore and Dundalk Vet Centers, ensures staff supervision occurs as required, and monitors compliance.
Closure Date:
18 The District Director verifies and determines reasons for noncompliance with monthly chart audits at the Baltimore, Dundalk, Raleigh, and Richmond Vet Centers; ensures chart audits are completed as required; and monitors compliance.
Closure Date:
19 The District Director determines reasons employees at the Baltimore, Dundalk, Raleigh, and Richmond Vet Centers did not complete required trainings; ensures all staff complete mandatory trainings; and monitors compliance.
Closure Date:
20 The District Director evaluates and determines reasons for noncompliance with a presentable exterior at the Richmond Vet Center and ensures all exterior grounds are in good repair.
Closure Date:
21 The District Director evaluates and determines reasons for noncompliance with tactile (braille) signage at the Baltimore, Dundalk, and Raleigh Vet Centers and ensures all exit doors are compliant with Architectural Barriers Act Accessibility Standards.
Closure Date:
22 The District Director reviews reasons for noncompliance with maintaining a current and comprehensive emergency and crisis plan at the Raleigh and Richmond Vet Centers and ensures all emergency and crisis plans are updated and comprehensive as required.
Closure Date:
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15039