All Reports

Inspection of VA Regional Office Indianapolis, Indiana
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14-04876-204

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/29/2016
We recommended the Indianapolis VA Regional Office Director develop and implement a plan to ensure staff take timely action on reminder notifications to request medical reexaminations.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/29/2016
We recommended the Indianapolis VA Regional Office Director conduct a review of the 353 temporary 100 percent disability evaluations remaining from their inspection universe as of September 2, 2014, and take appropriate action.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/29/2016
We recommended the Indianapolis VA Regional Office Director implement plans to ensure the effectiveness of training conducted on processing claims for Special Monthly Compensation and ancillary benefits.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 10/22/2015
We recommended the Indianapolis VA Regional Office Director implement a plan to ensure claims processing staff prioritize actions related to benefits reductions to minimize improper payments to veterans.
Federal Information Security Management Act Audit for Fiscal Year 2014
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14-01820-355

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Executive in Charge for Information and Technology fully develop policy to address Federal requirements and implement an agency-wide risk management governance structure, along with mechanisms to identify, monitor, and manage risks across the enterprise. (This is a repeat recommendation from prior years.)
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Executive in Charge 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 modified repeat recommendation from last year.)
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Executive in Charge for Information and Technology implement clear roles, responsibilities, and accountability for developing, maintaining, completing, and reporting Plans of Action and Milestones. (This is a modified repeat recommendation from prior years.)
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Executive in Charge 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.)
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Executive in Charge for Information and Technology develop mechanisms to ensure system security plans reflect current operational environments, including accurate system interconnections, boundary, and ownership information. (This is a modified repeat recommendation from last year.)
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Executive in Charge for Information and Technology implement improved processes for 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 modified repeat recommendation from last year.)
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Executive in Charge 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.)
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Executive in Charge 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.)
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Executive in Charge 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.)
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Executive in Charge for Information and Technology implement two-factor authentication for remote access throughout the agency. (This is a repeat recommendation from prior years.)
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Executive in Charge 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.)
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Executive in Charge for Information and Technology implement more effective automated mechanisms to continuously identify and remediate security deficiencies on VA¿s network infrastructure, database platforms, and Web application servers. (This is a modified repeat recommendation from last year.)
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Executive in Charge 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 modified repeat recommendation from last year.)
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Executive in Charge for Information and Technology implement improved processes for monitoring standard security configuration baselines for all VA operating systems, databases, applications, and network devices. (This is a modified repeat recommendation from last year.)
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Executive in Charge for Information and Technology implement improved network access controls to ensure medical devices and tenant networks are appropriately segregated from general networks and mission-critical systems. (This is a new recommendation)
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Executive in Charge for Information and Technology consolidate the security responsibilities for tenant networks present under a common control for each site and ensure vulnerabilities are remediated in a timely manner. (This is a new recommendation)
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
We recommended the Executive in Charge 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 modified repeat recommendation from last year.)
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Executive in Charge for Information and Technology implement processes to ensure information system contingency plans are updated with the required information. (This is a modified repeat recommendation from last year.)
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Executive in Charge 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.)
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Executive in Charge 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.)
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Executive in Charge for Information and Technology identify all external network interconnections and implement improved processes for monitoring VA networks, systems, and exchanges for unauthorized activity. (This is a modified repeat recommendation from last year.)
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Executive in Charge for Information and Technology implement and monitor incident response metrics to assist in tracking and remediating all cybersecurity events. (This is a new recommendation)
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Executive in Charge for Information and Technology develop a listing of approved software and implement continuous monitoring processes to identify and prevent the use of unauthorized application software, hardware, and system configurations on its networks. (This is a repeat recommendation from prior years.)
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Executive in Charge 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.)
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Executive in Charge 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 modified repeat recommendation from last year.)
No. 26
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Executive in Charge for Information and Technology implement mechanisms for updating the Federal Information Security Management Act systems inventory, including contractor-managed systems and interfaces, and annually review the systems inventory for accuracy. (This is a repeat recommendation from prior years.)
No. 27
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Executive in Charge for Information and Technology implement mechanisms to ensure all users with VA network access participate in and complete required VA-sponsored security awareness training. (This is a repeat recommendation from prior years.)
No. 28
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Executive in Charge for Information and Technology develop guidance and procedures to integrate information security costs into the capital planning process while ensuring traceability of Plans of Action and Milestones remediation costs to appropriate capital planning budget documents.
No. 29
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Assistant Secretary for Information and Technology develop mechanisms to ensure risk assessments accurately reflect the current control environment, compensating controls, and the characteristics of the relevant VA facilities.
No. 30
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Assistant Secretary for Information and Technology update all applicable position descriptions to better describe position sensitivity levels, and improve documentation of employee/contractor personnel records of ¿Rules of Behavior¿ and annual privacy training certifications.
No. 31
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Assistant Secretary for Information and Technology ensure appropriate levels of background investigations be completed for all applicable VA employees and contractors 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.
No. 32
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
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.
No. 33
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/15/2016
We recommended the Assistant Secretary for Information and Technology identify and deploy solutions to encrypt sensitive data and resolve clear text protocol vulnerabilities.
Combined Assessment Program Review of the VA St. Louis Health Care System, St. Louis, Missouri
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15-00075-351

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/18/2015
We recommended that the Facility Director continue to chair Quality Executive Board meetings.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/18/2015
We recommended that when cases receive initial Level 2 or 3 ratings, the Peer Review Committee consistently invite involved providers to submit comments to and/or appear before the committee prior to the final level assignment.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2017
We recommended that the Medical Executive Board and the Facility Director consistently review and approve all privilege forms annually and all revised privilege forms and document the review.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/21/2017
We recommended that facility managers ensure that licensed independent practitioners who perform emergency airway management have properly approved/signed privilege forms.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/21/2017
We recommended that the facility ensure that licensed independent practitioners’ folders do not contain non-allowed information.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/18/2015
We recommended that the facility implement a policy that defines Surgical Work Group membership.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/18/2015
We recommended that the Surgical Work Group document its review of National Surgical Office reports and its review of all surgical deaths with identified problems or opportunities for improvement.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/21/2017
We recommended that clinicians report all critical incidents through the facility’s adverse event reporting process.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2017
We recommended that the facility review the quality of entries in the electronic health record and analyze data at least quarterly.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/18/2015
We recommended that the facility fully implement the new quality control policy for scanning and that facility managers monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/21/2017
We recommended that Environment of Care Committee minutes include discussion regarding environment of care rounds deficiencies and that facility managers monitor compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/7/2017
We recommended that facility managers ensure patient care areas and public restrooms are clean and monitor compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/7/2017
We recommended that the facility repair damaged furniture in patient care areas or remove it from service.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/7/2017
We recommended that the facility store oxygen tanks in a manner that distinguishes between empty and full tanks and that facility managers monitor compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/7/2017
We recommended that facility managers ensure all electrical gang boxes have the appropriate covers installed.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/7/2017
We recommended that the facility store clean and dirty items separately and that facility managers monitor compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/7/2017
We recommended that the facility promptly remove outdated commercial supplies from sterile supply rooms and that facility managers monitor compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/21/2017
We recommended that the facility promptly remove expired medications from patient care areas and that facility managers monitor compliance.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/7/2017
We recommended that the facility label medications in accordance with local policy and that facility managers monitor compliance.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/7/2017
We recommended that the facility inspect alarm-equipped medical devices according to local policy and the manufacturers’ recommendations and that facility managers monitor compliance.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2017
We recommended that the facility document functionality checks of the community living center’s elopement prevention system at least every 24 hours and conduct and document annual complete system checks and that facility managers monitor compliance.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/7/2017
We recommended that the facility inspect and tag critical medical equipment in the community living center and that facility managers monitor compliance.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/18/2015
We recommended that facility managers ensure crash cart logs contain the correct lock numbers and monitor compliance.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/18/2015
We recommended that the facility ensure the look-alike and sound-alike medication list is available for staff reference in all areas.
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/18/2015
We recommended that the facility ensure the high-alert medication list is available for staff reference.
No. 26
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/18/2015
We recommended that the facility create/designate a committee to oversee consult management.
No. 27
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/18/2015
We recommended that the Medicine, Mental Health, Surgical, and Rehabilitation Services’ Automated Data Processing Applications Coordinators provide training in the use of the computerized consult package and that facility managers monitor compliance.
No. 28
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/18/2015
We recommended that Medicine, Mental Health, Surgical, and Rehabilitation Services designate an individual to review and manage consults.
No. 29
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/18/2015
We recommended that requestors consistently select the proper consult title and that facility managers monitor compliance.
No. 30
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/18/2015
We recommended that the facility complete secondary patient safety screenings immediately prior to magnetic resonance imaging and that facility managers monitor compliance.
No. 31
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/18/2015
We recommended that radiologists and/or Level 2 magnetic resonance imaging personnel document resolution in patients’ electronic health records of all identified magnetic resonance imaging contraindications prior to the scan and that facility managers monitor compliance.
No. 32
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/18/2015
We recommended that the facility ensure all designated Level 1 ancillary staff receive annual level-specific magnetic resonance imaging safety training and that facility managers monitor compliance.
No. 33
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/18/2015
We recommended that the facility ensure all designated Level 2 magnetic resonance imaging personnel receive annual level-specific magnetic resonance imaging safety training and that facility managers monitor compliance.
No. 34
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/21/2017
We recommended that the facility revise the stroke policy to address a stroke team and data gathering for analysis and improvement and that facility managers fully implement the revised policy.
No. 35
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/21/2017
We recommended that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that facility managers monitor compliance.
No. 36
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2017
We recommended that the facility collect and report to the Veterans Health Administration the percent of patients with stroke symptoms who had the stroke scale completed and the percent of patients screened for difficulty swallowing before oral intake.
No. 37
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/18/2015
We recommended that Radiology Service revise the computed tomography scan, magnetic resonance imaging/magnetic resonance angiograms, and radiology interpretation on-call policy to require a 30-minute reporting time.
No. 38
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2017
We recommended that the facility ensure initial clinician emergency airway management competency assessment includes all required elements and that facility managers monitor compliance.
No. 39
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/21/2017
We recommended that the facility ensure clinician reassessment for continued emergency airway management competency is completed at the time of renewal of privileges or scope of practice and that facility managers monitor compliance.
No. 40
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/21/2017
We recommended that the facility ensure clinician reassessment for continued emergency airway management competency includes completion of all required elements at the time of renewal of privileges or scope of practice and that facility managers monitor compliance.
No. 41
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/18/2015
We recommended that the facility ensure that clinicians reassessed for continued emergency airway management have a statement related to emergency airway management included in an approved scope of practice.
No. 42
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/21/2017
We recommended that the facility ensure a clinician with emergency airway management privileges or scope of practice or an anesthesiology staff member is available during all hours the facility provides patient care and that facility managers monitor compliance.
No. 43
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/21/2017
We recommended that facility managers strengthen processes to minimize a repeat occurrence in which non-privileged providers perform intubations and in instances of occurrence, initiate root cause analyses.
No. 44
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/18/2015
We recommended that facility managers ensure that only authorized patients, staff, and visitors access the Domiciliary Residential Rehabilitation Treatment Program.
No. 45
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/18/2015
We recommended that facility managers ensure that the Domiciliary Residential Rehabilitation Treatment Program does not have closed circuit television in treatment areas.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Puget Sound Health Care System, Seattle, Washington
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15-00112-338

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/6/2016
We recommended that managers ensure review of the hazardous materials inventory occurs twice within a 12-month period at the North Olympic Peninsula CBOC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/6/2016
We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/16/2016
We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing and health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/16/2016
We recommended that providers and clinical associates in the outpatient clinics receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/6/2016
We recommended that the Facility Director develops policies and procedures that facilitate human immunodeficiency virus testing as part of routine medical care for patients.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/6/2016
We recommended that the Facility Director defines the requirements for communication of human immunodeficiency virus test results.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/6/2016
We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
Combined Assessment Program Review of the VA Nebraska-Western Iowa Health Care System, Omaha, Nebraska
|
15-00076-350

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/22/2015
We recommended that the Accident Review Board gather, track and share patient handling injury data.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2016
We recommended that the facility include most services and program areas in the review of electronic health record quality.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/22/2015
We recommended that the facility institute unique refrigerator bin storage practices for look-alike and sound-alike medications in all areas and that facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/3/2015
We recommended that radiologists and/or Level 2 magnetic resonance imaging personnel document resolution in patients' electronic health records of all identified magnetic resonance imaging contraindications prior to the scan and that facility managers monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2016
We recommended that clinicians complete and document National Institutes of Health stroke scales for each patient and that facility managers monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2016
We recommended that clinicians provide printed stroke education to patients upon discharge and that facility managers monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2016
We recommended that the facility ensure that employees who are involved in assessing and treating stroke patients receive the training required by the facility and that facility managers monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2016
We recommended that the facility ensure clinician reassessment for continued emergency airway management competency includes reviews of clinician-specific emergency airway management data and that facility managers monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2016
We recommended that the facility ensure clinician reassessment for continued emergency airway management competency includes all required subject matter content elements and completion of a written test and that facility managers monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2016
We recommended that the facility ensure that clinician reassessment for continued emergency airway management competency includes one of the three required components and that facility managers monitor compliance.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Boston Healthcare System, Boston, Massachusetts
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15-00126-342

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/14/2015
We recommended that staff protect patient-identifiable information on laboratory specimens during transport from the Causeway VA Clinic to the parent facility.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/13/2016
We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/24/2015
We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/24/2015
We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing training within 12 months of appointment to Patient Aligned Care Teams.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/24/2015
We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/14/2015
We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
FY 2014 Review of VA’s Compliance With the Improper Payments Elimination and Recovery Act
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14-03380-356

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/27/2016
We recommended the Interim Under Secretary for Health ensure implementation of the revised sampling plan for the Civilian Health and Medical Program of the Department of Veterans Affairs to address sample outliers and adjust the program¿s reduction target to a reasonably achievable level, if necessary.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/16/2016
We recommended the Under Secretary for Benefits monitor the results of the Veterans Benefits Administration¿s revised testing plans for the Compensation, Pension, Montgomery G.I. Bill, and Vocational Rehabilitation and Employment programs and adjust the reduction targets to reasonably achievable levels, if necessary.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/16/2016
We recommended the Under Secretary for Benefits implement revised testing plans for the Post-9/11 G.I. Bill and its other reported Education programs that ensure valid and auditable estimates of improper payments.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 1/27/2016
We recommended that the Acting Assistant Secretary for Management improve the risk assessment guidance and instructions to include an assessment of risk associated with contracting activities.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 2/1/2017
We recommended that the Acting Assistant Secretary for Management perform risk assessments for programs with a high concentration of vendor payments using revised procedures that include contracting risk.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/8/2016
We recommended that the Under Secretary for Benefits ensure thorough testing of sample items used to estimate improper payments for the Compensation program.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 10/9/2015
We recommended that the Under Secretary for Benefits consult with the Office of Management and Budget regarding the potential designation of the Compensation program as a high-priority program.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/16/2016
We recommended that the Under Secretary for Benefits use the annual Department of Defense drill pay matching file to identify improper drill pay-related payments in its Compensation and Pension program samples to ensure accurate and auditable reporting.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/27/2016
We recommended that the Interim Under Secretary for Health improve test procedures for the Non-VA Medical Care and Purchased Long Term Services and Support programs by verifying the existence of valid contracts that support payments for these programs.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Nebraska-Western Iowa Health Care System, Omaha, Nebraska
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15-00124-227

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that fire drills are performed every 12 months at the O’Neill VA Clinic.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing training within 12 months of appointment to Patient Aligned Care Teams.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that providers and clinical associates in the outpatient clinics receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director develops policies and procedures that facilitate human immunodeficiency virus testing as part of routine medical care for patients.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Palo Alto Health Care System, Palo Alto, California
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15-00110-228

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/23/2015
We recommended that employees at the Fremont CBOC receive the required training on hazardous materials.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/18/2016
We recommended that staff protect patient-identifiable information on laboratory specimens during transport from the Fremont CBOC to the parent facility.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2015
We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/24/2016
We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing and health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/24/2016
We recommended that providers and clinical associates in the outpatient clinics receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2015
We recommended that the Facility Director develops policies and procedures that facilitate human immunodeficiency virus testing as part of routine medical care for patients
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/30/2016
We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Roseburg Healthcare System, Roseburg, Oregon
|
15-00129-339

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/14/2016
We recommended that managers ensure that all safety inspections are performed on the medical equipment at the Brookings CBOC in accordance with Joint Commission standards.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/31/2016
We recommended that managers monitor hand hygiene compliance at the Brookings CBOC and report compliance levels to the Infection Control Committee.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/5/2015
We recommended that the information technology staff maintain the information technology server closet at the Brookings CBOC according to information technology safety and security standards.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/25/2017
We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/25/2016
We recommended that clinic staff provide education and counseling for patients with positive alcohol screens and alcohol consumption above National Institute on Alcohol Abuse and Alcoholism limits.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/25/2016
We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/22/2015
We recommended that Clinic Registered Nurse Care Managers and clinical associates receive health coach training as required.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/22/2015
We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
Review of Alleged Mismanagement of Radiologists Interpretations at Central Arkansas Veterans Healthcare System
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14-04493-198

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/19/2015
We recommended the Interim Veterans Integrated Service Network 16 Director review TalkStation data showing the time interpretations started and ended to ensure radiologists perform Teleradiology Reading Center interpretations during their non-duty hours.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/30/2015
We recommended the Interim Veterans Integrated Service Network 16 Director require the Central Arkansas Veterans Healthcare System to establish policy on an official tour of duty for weekends to ensure radiologists perform Teleradiology Reading Center interpretations during their non-duty hours.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/29/2016
We recommended the Interim Veterans Integrated Service Network 16 Director annually review the Teleradiology Reading Center agreement and certify that services are still needed, qualified individuals in the specialty are not available locally, and other business options have been considered for obtaining services.
Combined Assessment Program Review of the VA Palo Alto Health Care System, Palo Alto, California
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15-00032-226

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/5/2016
We recommended that the facility establish a committee to provide oversight of the safe patient handling program.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2015
We recommended that facility managers ensure employees receive training on chemical labeling/safety data sheets.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2015
We recommended that the facility store clean and dirty items separately and that facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/5/2016
We recommended that facility managers ensure personal protective equipment gowns, eye protection, and masks are available in various sizes in patient care areas and monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2015
We recommended that facility managers ensure all designated critical care and community living center employees receive annual bloodborne pathogens training and monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/5/2016
We recommended that the facility conduct initial patient safety screenings prior to magnetic resonance imaging and that facility managers monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/5/2016
We recommended that Level 2 magnetic resonance imaging personnel conducting secondary patient safety screenings sign the forms prior to magnetic resonance imaging and that facility managers monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/5/2016
We recommended that radiologists and/or Level 2 magnetic resonance imaging personnel document resolution in patients' electronic health records of all identified magnetic resonance imaging contraindications prior to the scan and that facility managers monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2015
We recommended that the facility ensure all designated Level 1 ancillary staff receive annual level-specific magnetic resonance imaging safety training and that facility managers monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/9/2016
We recommended that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that facility managers monitor compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/30/2015
We recommended that facility managers post stroke guidelines on the critical care and medical/surgical units.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/8/2016
We recommended that clinicians provide printed stroke education to patients upon discharge and that facility managers monitor compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2015
We recommended that the facility report to the Medical Executive Board the percent of eligible patients given tissue plasminogen activator, the percent of patients with stroke symptoms who had the stroke scale completed, and the percent of patients screened for difficulty swallowing before oral intake.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/9/2016
We recommended that clinicians obtain cardiac markers, prothrombin time/international normalized ratio, and partial thromboplastin time while assessing patients presenting with stroke symptoms and that facility managers monitor compliance.
Review of VA's Patient-Centered Community Care (PC3) Contracts' Estimated Costs Savings
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14-02916-336

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2016
We recommended the Interim Under Secretary for Health assign an accountable senior executive to prepare and document revised Patient-Centered Community Care price analyses and determine if VA will realize any cost savings during the future option years of the contracts.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2016
We recommended the Interim Under Secretary for Health develop an action plan to address low PC3 contract utilization rates.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 9/9/2015
We recommended the Executive Director, Office of Acquisition, Logistics, and Construction ensure all required contract documents are maintained in the official Patient-Centered Community Care contract files in accordance with Federal Acquisition Regulation and hold the contracting officer accountable for ensuring complete and accurate information is maintained in the Electronic Contract Management System.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Ralph H. Johnson VA Medical Center, Charleston, South Carolina
|
15-00114-212

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/17/2015
We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/17/2015
We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
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