Recommendations
2156
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 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.
Closure Date:
2 Executive leaders review the change in laboratory scheduling practices and minimize its effect on clinic efficiency.
Closure Date:
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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.
Closure Date:
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| 24-00568-38 | Review of Data Security and Oversight Processes of a Veterans Health Administration National Cancer Prevention, Treatment, and Research Program | National Healthcare Review | ||
1 The Executive Director of Operations for a national cancer testing program ensures the project has met the requirements for Institutional Review Board review for research with human subjects and takes action as needed.
2 The Executive Director of Operations for a national cancer testing program ensures national cancer prevention, treatment, and research program staff are trained on Institutional Review Board project submission and privacy requirements.
3 The National Specialty Care Program Office Chief Officer ensures the national cancer prevention, treatment, and research program staff reviews and provides required approvals before the release of protected health information for research.
4 The National Specialty Care Program Office Chief Officer, in conjunction with the Office of Research & Development ensures that VA privacy officers report privacy incidents involving data obtained from or for national cancer prevention, treatment, and research program activities timely and monitors for compliance.
5 The Office of Research Oversight Executive Director in conjunction with the Chief Research and Development Officer, VHA Office of Research & Development, reviews the national cancer prevention, treatment, and research program final mitigation plan and ensures corrective actions address system-wide issues for determining whether a national cancer prevention, treatment, and research program project constitutes research, safeguarding privacy when data is shared for projects, and ensuring data security requirements are met.
6 The National Specialty Care Program Office Chief Officer ensures the national cancer prevention, treatment, and research program has safeguards in place including biostatistician expertise to ensure that data containing sensitive patient information and protected health information is deidentified before sharing outside of VA as required.
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| 24-03708-141 | Follow-Up Inspection of Information Security at the VA Beckley Healthcare System in West Virginia | 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.
Closure Date:
2 Develop and approve an authorization to operate for the special-purpose systems.
Closure Date:
3 Include facility personnel during the security categorization process to ensure all necessary information types are considered when determining the security categorization for special-purpose systems.
Closure Date:
4 Segregate the pharmacy application administrative access from individuals who are custodians of the pharmaceutical inventory.
Closure Date:
5 Ensure a witness observes the destruction of temporary paper files that contain personally identifiable information and protected health information.
Closure Date:
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15461