All Reports

VA Medical Facilities Took Steps to Safeguard Refrigerated Pharmaceuticals but Could Further Reduce the Risk of Loss
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21-01898-152
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Topics:  Supplies and Equipment

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/6/2023
Direct the assistant under secretary for health operations to reinforce to medical facility directors the importance of establishing a process to ensure facility managers include pharmaceutical refrigerators and freezers in the facility’s routine maintenance schedules and develop and implement a procedure to make sure medical facilities follow VHA Notice 2021-16.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/30/2022
Require the assistant under secretary for patient care services to coordinate with the assistant under secretary for health operations to update the 10N Guide to VHA Issue Briefs and clarify that medical facilities must report all refrigerated pharmaceutical loss via the issue brief tracker.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 5,100,000.00
Failure of Leaders to Address Safety, Staffing, and Environment of Care Concerns at the Tuscaloosa VA Medical Center in Alabama
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21-03201-185
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Topics:  Patient Safety ● Staffing

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/13/2023
The Tuscaloosa VA Medical Center Director provides oversight of the purchase and installation of an electronic alarm system for all Community Living Center neighborhoods and cottages and confirms ongoing monitoring of its use after installation.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/23/2022
The Tuscaloosa VA Medical Center Director confirms completion of the risk analysis recommended in the facility-initiated risk assessment to determine if the Azalea House is suitable for the patient population residing there.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2023
The Tuscaloosa VA Medical Center Director ensures that all security cameras are operable and labeled appropriately and develops and monitors a plan for ongoing testing and maintenance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/27/2023
The Tuscaloosa VA Medical Center Director directs staff to assess the effectiveness of the outdoor fencing and gates surrounding Azalea House as a security measure to prevent Community Living Center residents at-risk for elopement from leaving the facility campus.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/24/2023
The Tuscaloosa VA Medical Center Director establishes a review process to ensure that Community Living Center residents determined to be high risk for elopement have documentation consistent with Tuscaloosa VA Medical Center policy in their electronic health records identifying residents’ risk status.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/27/2023
The Tuscaloosa VA Medical Center Director collaborates with the Veterans Integrated Service Network 7 Senior Strategic Business Partner to determine difficult to fill job series and develops a plan to maximize use of available tools for coverage, recruitment, and retention.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/27/2023
The Tuscaloosa VA Medical Center Director ensures completion of a review of the facility’s Comprehensive Environment of Care program to confirm that patient care areas are properly classified, all areas are inspected at the required frequency, and compliance is monitored.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/27/2023
The Tuscaloosa VA Medical Center Director coordinates with subject matter experts and develops a plan to ensure that the facility’s Comprehensive Environment of Care program effectively identifies areas in need of attention to provide a clean and safe environment for patients, visitors, and staff.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/27/2023
The Tuscaloosa VA Medical Center Director confirms that Engineering Service staff conduct rounds of the grounds according to Tuscaloosa VA Medical Center policy.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/10/2023
The VA Southeast Network 7 Director ensures completion of the Tuscaloosa VA Medical Center’s action plan to address recommendations made as a result of the October 2021 Veterans Integrated Service Network site visit.
Multiple Failures in Test Results Follow-up for a Patient Diagnosed with Prostate Cancer at the Hampton VA Medical Center in Virginia
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21-03349-186
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Topics:  Care Coordination ● Community Care ● Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/18/2023
The Hampton VA Medical Center Director ensures that providers communicate, act on, and document a review of test results consistent with Veterans Health Administration policy.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/12/2023

The Hampton VA Medical Center Director determines why the abnormal prostate-specific-antigen test results were not alerted to an ordering or surrogate provider and if other patient test results during that time frame also warrant review.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/3/2023
The Hampton VA Medical Center Director ensures that abnormal test results are timely communicated to providers or providers’ surrogates.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/24/2023
The Hampton VA Medical Center Director reviews the urology consult template and, if appropriate, ensures the specific imaging required for consultation is specified in the template.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/24/2023
The Hampton VA Medical Center Director ensures that procedures are in place to identify and reduce errors when staff place nuclear medicine orders.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/24/2023
The Hampton VA Medical Center Director ensures that facility staff submit patient safety reports consistent with Veterans Health Administration and Hampton VA Medical Center policy.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/24/2023
The Hampton VA Medical Center Director ensures that quality management staff initiate timely quality reviews when deficiencies in patient care are identified.
Review of VA’s Compliance with the Payment Integrity Information Act for Fiscal Year 2021
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22-00576-178
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Topics:  Financial Management

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/29/2023
The acting under secretary for health take necessary measures to reduce improper and unknown payments to below 10 percent for Beneficiary Travel, Medical Care Contracts and Agreements, Purchased Long-Term Services and Supports, and VA Community Care programs and activities.
Mission Accountability Support Tracker Lacked Sufficient Security Controls
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21-03080-142
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Topics:  Information Technology and Security

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 10/25/2022
The OIG recommends the Assistant Secretary for Information and Technology develop controls to help ensure minor applications are not misclassified as assets and undergo the appropriate security accreditation and certification process.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT),Veterans Benefits Administration (VBA)
Closure Date: 8/7/2023
The OIG recommends the Assistant Secretary for Information and Technology in conjunction with the Under Secretary for Benefits, make certain that appropriate security and privacy controls are implemented during the development of information technology systems before being hosted on VA’s network.
No. 3
Open Recommendation Image, Square
to Information and Technology (OIT),Veterans Benefits Administration (VBA)
The OIG recommends the Under Secretary for Benefits, in conjunction with the Assistant Secretary for Information and Technology, establish a mechanism to gain assurance that proper Office of Information Technology project management processes and protocols are followed when establishing information technology systems and applications.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 10/25/2022
The OIG recommends the Under Secretary for Benefits establish policies and procedures to ensure the Mission Accountability Support Tracker is used appropriately and does not contain unnecessary personally identifiable information.
Comprehensive Healthcare Inspection of the Washington DC VA Medical Center
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21-00288-175
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Topics:  Suicide Prevention ● Care Coordination

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/15/2022
The Executive Director evaluates and determines reasons for noncompliance and ensures leaders identify adverse events as sentinel events when criteria are met and conduct institutional disclosures as required.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/31/2023
The Executive Director evaluates and determines any additional reasons for noncompliance and designates a systems redesign and improvement coordinator.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/31/2023
The Executive Director evaluates and determines any additional reasons for noncompliance and makes certain that credentialing staff complete primary source verification of all registered nurses’ licenses prior to initial appointment.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/15/2022
The Associate Director, Clinical Services evaluates and determines any additional reasons for noncompliance and ensures staff complete mandatory suicide safety plan training prior to developing suicide safety plans.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/15/2022
The Associate Director, Clinical Services and Associate Director, Patient Care Services evaluate and determine reasons for noncompliance and ensure staff monitor and evaluate all inter-facility transfers as part of VHA’s Quality Management Program.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/2/2023
The Associate Director, Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures nurse-to-nurse communication occurs between sending and receiving facilities.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/31/2023
The Executive Director evaluates and determines any additional reasons for noncompliance and ensures Employee Threat Assessment Team meetings are held and members complete training, as required.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/31/2023
The Associate Director, Clinical Services and Associate Director, Patient Care Services evaluate and determine any additional reasons for noncompliance and make certain that required members attend Disruptive Behavior Committee meetings.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/4/2024

The Executive Director evaluates and determines any additional reasons for noncompliance and ensures employees complete all required prevention and management of disruptive behavior training based on the risk level assigned to their work areas.

Financial Efficiency Review of the VA El Paso Healthcare System in Texas and New Mexico
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21-02197-165
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Topics:  Financial Management

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/23/2022
Ensure healthcare system finance office staff are made aware of policy requirements for open obligations and the responsible healthcare system finance office conducts reviews on all open obligations as required by VA Financial Policies and Procedures, Volume II, Chapter 5, “Obligations Policy,” October 2020.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/6/2023
Establish procedures to ensure cardholders comply with record retention and transaction-processing requirements as stated in VA’s Financial Policy, vol. XVI, “Charge Card Program.”
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/1/2023
Develop a plan to work with the prime vendor to address having adequate stock to meet orders, reducing the need for the healthcare system to use nonprime vendors.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/23/2022
Ensure the healthcare system follows the Medical Surgical Prime Vendor-Next Generation ordering hierarchy and purchases items from the Medical Surgical Prime Vendor-Next Generation contract before using other sources.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/23/2022
Ensure the healthcare system elects and is granted a delivery method that meets just-in-time requirements.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/1/2023
Ensure the healthcare system submits Medical Surgical Prime Vendor-Next Generation waiver requests and obtains approval before purchasing available formulary items from nonprime vendor sources.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/23/2022
Ensure logistics staff and contracting officer’s representatives use all the tools available to inform the Medical Supplies Program Office and Strategic Acquisition Center of prime vendor performance issues.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/23/2022
Develop formalized processes for achieving identified efficiency targets and use available pharmacy data to make business decisions.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/23/2022
Educate non-VA providers on prescribing lower-cost drugs.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/4/2023
Develop and implement a plan to increase inventory turnover to the Veterans Health Administration-recommended level.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/1/2023
Develop and implement a plan to complete facility-based inventory audits of noncontrolled drug line items in compliance with Veterans Health Administration policy.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/4/2023
Develop a plan to ensure that appropriate metrics for monitoring compliance with Veterans Health Administration policy are calculated correctly in the Pharmacy Benefits Management inventory reporting tool.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 185,533.00
Comprehensive Healthcare Inspection of the VA Maryland Health Care System in Baltimore
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21-00283-173
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Topics:  Patient Safety ● Care Coordination

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/22/2022
The Chief of Staff evaluates and determines additional reasons for noncomplianceand ensures that peer reviewers use at least one of the nine aspects of care forevaluations.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/22/2022
The Chief of Staff evaluates and determines any additional reasons fornoncompliance and ensures that the Peer Review Committee recommendsimprovement actions for Level 3 peer reviews.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/22/2022
The Chief of Staff evaluates and determines any additional reasons fornoncompliance and makes certain that the Peer Review Committee completes finalpeer reviews within 120 calendar days from the date it is determined a peer reviewis required, or the System Director approves any necessary extensions in writing.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2023
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and make certain that staff monitor and evaluate all transfers as part of VHA’s Quality Management Program.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2023
The Chief of Staff and Associate Director for Patient Care Services evaluate anddetermine any additional reasons for noncompliance and ensure that transferringproviders complete all elements of the VA Inter-Facility Transfer Form or afacility-defined equivalent note in the electronic health record.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2023
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure that transferring providers send patients’ active medication lists to receiving facilities during inter-facility transfers.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/29/2024

The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that nurse-to-nurse communication occurs between sending and receiving facilities.

No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/10/2024

The System Director evaluates and determines any additional reasons for noncompliance and ensures employees complete all required prevention and management of disruptive behavior training based on the risk level assigned to their work area.

Contract Medical Exam Program Limitations Put Veterans at Risk for Inaccurate Claims Decisions
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21-01237-127
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Topics:  Claims and Medical Exams

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/24/2023
Assess and modify contracts and any renewals to ensure that vendors can be heldaccountable for unsatisfactory performance by applying monetary disincentives.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/5/2023
Assess and modify contracts and any renewals to ensure procedures are established for vendors to correct errors identified by the Medical Disability Examination Office.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/5/2023
Implement procedures requiring the Medical Disability Examination Office tocommunicate exam errors to the Office of Field Operations and the regional officesand demonstrate progress in correcting the identified errors.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/10/2022
Implement procedures requiring the Medical Disability Examination Office toanalyze all available error data and provide systemic exam issues and error trends tovendors.
Suicide Prevention Coordinators Need Improved Training, Guidance, and Oversight
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20-02186-78
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Topics:  Mental Health

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/12/2023
Ensure program officials in collaboration with regional and local leaders address call management system data integrity issues before they use data to assess the management of referrals.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/1/2023
Have the program office develop formal training and guidance for coordinators on how to use patient outcome codes and regional and local leaders ensure the training is completed.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/1/2023
Ensure regional and local managers regularly review crisis line referral information in the electronic health records to verify coordinators are completing and documenting appropriate follow-up on referrals and the program office performs regular audits, monitors, reports upon, and initiates actions, as needed, to ensure compliance with and completion of referral follow-up.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/12/2023
Consider guidance within coordinators’ training tools to clarify the expectations for coordinators to follow up on referred veterans who have been hospitalized in a non-VA hospital, admitted to an emergency department (VA and non-VA), or provided a welfare check.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/1/2023
Have regional and local managers monitor coordinators’ call attempts to ensure they are interspersed over a three-day period and provide them with referral closure information to assist in their monitoring.
Comprehensive Healthcare Inspection of the Beckley VA Medical Center in West Virginia
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21-00286-163
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Topics:  Suicide Prevention ● Care Coordination

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/2/2022
The Medical Center Director evaluates and determines any additional reasons fornoncompliance and makes certain that the Surgical Workgroup Committee meets atleast monthly.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/2/2022
The Chief of Staff evaluates and determines any additional reasons fornoncompliance and ensures staff complete mandatory suicide safety plan trainingprior to developing suicide safety plans.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/2/2022
The Chief of Staff and Associate Director/Patient Care Services evaluate anddetermine any additional reasons for noncompliance and ensure staff send activemedication lists to receiving facilities during inter-facility transfers.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/2/2023
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures all staff complete the required prevention and management of disruptive behavior training based on the risk level assigned to their work area.
Comprehensive Healthcare Inspection of the Hershel Woody Williams VA Medical Center in Huntington, West Virginia
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21-00293-170
|
Topics:  Care Coordination

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/2/2022
The Medical Center Director evaluates and determines any additional reasons fornoncompliance and ensures leaders conduct institutional disclosures for all sentinelevents.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/12/2023
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the Systems Redesign Coordinator participates on the Quality, Safety & Value Council.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/25/2022
The Medical Center Director evaluates and determines any additional reasons fornoncompliance and makes certain that the Facility Surgical Work Group meets atleast monthly.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/25/2022
The Medical Center Director evaluates and determines any additional reasons fornoncompliance and ensures that core members consistently attend Facility SurgicalWork Group meetings.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2024

The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure that the referring physician completes all required elements of the VA Inter-Facility Transfer Form or facility-defined equivalent note.

No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/16/2023

The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and make certain that required representatives attend the Disruptive Behavior Committee meetings.

Inspection of Information Technology Security at the Consolidated Mail Outpatient Pharmacy in Tucson, Arizona
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21-02453-99
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Topics:  Information Technology and Security

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/1/2022
Implement more effective inventory management tools for all network segments.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 9/29/2022
Implement a more effective vulnerability and flaw remediation program that can accurately identify vulnerabilities and enforce flaw remediation.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/1/2022
Develop and implement methods to ensure delivery, receipt, and understanding of assigned roles and responsibilities for Consolidated Mail Outpatient Pharmacy activities to ensure full implementation of approved policy.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 9/25/2023
Develop and implement a disaster recovery plan and capability that will restore operations in the event of a disruption to critical operations.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/1/2022
Task the facility manager to change the default username and password for the security camera system.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 9/29/2022
Request the Office of Information and Technology to configure audit logging on the misconfigured devices in accordance with established baselines, policy, and procedures.
Deficits with Metrics Following Implementation of the New Electronic Health Record at the Mann-Grandstaff VA Medical Center in Spokane, Washington
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21-03020-168
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Topics:  Electronic Health Records Modernization (EHRM) ● Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2024

The Deputy Secretary completes an evaluation of gaps in new electronic health record metrics and takes action as warranted.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/9/2024

The Deputy Secretary completes an evaluation of factors affecting the availability of metrics and takes action as warranted.

Veterans Data Integration and Federation Enterprise Platform Lacks Sufficient Security Controls
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21-01123-97
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Topics:  Information Technology and Security

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No. 1
Not Implemented Recommendation Image, X character'
to Information and Technology (OIT)
Closure Date: 8/7/2023
The assistant secretary for information and technology and chief information officer will ensure the Veterans Data Integration and Federation Enterprise Platform security objectives are all set at a categorization level of high based upon both the sensitive personal information maintained in the system and the approved risk assessment.
No. 2
Not Implemented Recommendation Image, X character'
to Information and Technology (OIT)
Closure Date: 8/7/2023
The assistant secretary for information and technology and chief information officer will act to reestablish the Veterans Data Integration and Federation Enterprise Platform in the Enterprise Mission Assurance Support Service to ensure appropriate security controls are implemented and the system is assessed at the high risk level.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 1/4/2023
The assistant secretary for information and technology and chief information officer will ensure the Office of Information Technology provides appropriate oversight and follows proper program management processes and protocols when establishing and monitoring security controls for IT systems.
Inspection of Information Technology Security at the Consolidated Mail Outpatient Pharmacy in Dallas, Texas
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21-03305-139
|
Topics:  Information Technology and Security

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 Information and Technology (OIT)
Closure Date: 10/20/2022
Implement an effective inventory management system for all network segments.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/23/2023
Implement an effective vulnerability and flaw remediation program that can accurately identify vulnerabilities and enforce flaw remediation
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/1/2022
Develop and implement methods to ensure delivery, receipt, and understanding of assigned roles and responsibilities for local activities to ensure full implementation of approved policy.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/1/2022
Implement effective configuration control processes that ensure network devices maintain standards mandated by the VA Office of Information and Technology Configuration Control Board.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 1/14/2025

Remove or disable group accounts to comply with established requirements and criteria.

No. 6
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/1/2022
Ensure employees lock devices when they are unattended.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/1/2022
Implement database authentication processes that comply with National Institute of Standards and Technology standards and VA security requirements.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 10/20/2022
Implement a process to retain database logs for a period consistent with VA’s record retention policy.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/1/2022
Establish a process for validating and logging the sanitization of hard drives.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 10/20/2022
Implement parking barriers that meet VA Physical Security & Resiliency Design Manual requirements.
Comprehensive Healthcare Inspection of Veterans Integrated Service Network 2: New York/New Jersey VA Health Care Network in Bronx, New York
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21-00240-158
|
Topics:  Medical Staff Privileging Credentialing

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/17/2023
The Chief Medical Officer evaluates and determines additional reasons for noncompliance and makes certain to review the credentials file and approve the VA appointment for physicians who had a potentially disqualifying licensure action.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/17/2023
The Network Director evaluates and determines any additional reasons for noncompliance and ensures that the Emergency Management Committee conducts annual reviews of the Emergency and Continuity of Operations Plans; Hazards Vulnerability Analysis; and Veterans Integrated Service Network-wide strengths, weaknesses, priorities, and requirements for improvement, and submits the reviews to executive leaders for approval.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/18/2022
The Network Director evaluates and determines any additional reasons for noncompliance and appoints a permanent Veterans Integrated Service Network lead women veterans program manager.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/17/2023
The Network Director evaluates and determines any additional reasons for noncompliance and makes certain that a lead women veterans program manager conducts yearly visits at each facility in the Veterans Integrated Service Network.
Failure to Provide Emergency Care to a Patient and Leaders’ Inadequate Response to that Failure at the Malcom Randall VA Medical Center in Gainesville, Florida
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20-04443-167
|
Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/13/2022
The VA Sunshine Healthcare Network Director ensures a review of the patient incident is conducted to determine whether further administrative action or reporting to state licensing board(s), or both, is warranted for facility staff involved in the incident, and takes action as appropriate.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/13/2022
The Malcom Randall VA Medical Center Director ensures that Emergency Department nurses and Administrative Officers of the Day prioritize patient care before patient eligibility status when patients present with an emergency medical condition, holds staff accountable when violations occur, and monitors for ongoing compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/13/2022
The Malcom Randall VA Medical Center Director ensures that Emergency Department nurse competencies are current, complete, and validated as required, and monitors for ongoing compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/13/2022
The Malcom Randall VA Medical Center Director conducts an internal review of the Emergency Department Nurse Educator’s replication of the 2019 Ongoing Competency Assessments and attestation of competency completion to determine whether administrative action is warranted and takes action as appropriate.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/13/2022
The Malcom Randall VA Medical Center Director evaluates the status of action plans referenced in this report and monitors the implementation and efficacy of action items to closure.
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