All Reports

VA Police Information Management System Needs Improvement
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19-05798-107
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Topics:  VA Police

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 4/14/2022
The OIG recommends that the Assistant Secretary for Human Resources and Administration/Operations, Security, and Preparedness in consultation with the Under Secretary for Health evaluate the appropriateness of having the Law Enforcement Training Center serve as the manager of the records management systems for VA police.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 7/21/2021
The OIG recommended the Assistant Secretary for Human Resources and Administration/Operations, Security, and Preparedness in consultation with the Assistant Secretary for Information and Technology, as well as the Under Secretary for Health establish a working group of subject matter experts and evaluate whether the Report Exec system meets the needs of VA police. The group should evaluate if the system meets police needs and whether contract requirements have been fully achieved, then develop a strategy to ensure that police units at all medical facilities have a reliably performing records management system to report and track activities.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 10/22/2021
The OIG recommended the Assistant Secretary for Human Resources and Administration/Operations, Security, and Preparedness in consultation with the Principal executive Director for the Office of Acquisition, Logistics and Construction; the Assistant Secretary for Information and Technology; and the Under Secretary for Health develop and implement a plan describing how, when, and to whom information about issues for the police records management system will be disseminated and resolved.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 4/14/2022
The OIG recommended the Assistant Secretary for Human Resources and Administration/Operations, Security, and Preparedness, in consultation with the Under Secretary for Health, update security and law enforcement program procedures to ensure they meet information management needs and requirements.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 12/18/2020
The OIG recommended the Assistant Secretary for Human Resources and Administration/Operations, Security, and Preparedness in consultation with the Assistant Secretary for Information and Technology and Principal Executive Director for the Office of Acquisition, Logistics and Construction initiate an agreement with the contractor to ensure information security measures are in place for the VA police records that were stored on the contractor’s server to prevent unauthorized use and their proper disposal.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 10/22/2021
The OIG recommended the Assistant Secretary for Human Resources and Administration/Operations, Security, and Preparedness in consultation with the General Counsel and the Assistant Secretary for Office of Accountability and Whistleblower Protection determine the appropriate administrative action to take, if any, against personnel involved in bypassing the requirement that the Report Exec system be hosted at the Austin Information Technology Center and the VA information security process be completed before operation.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 10/20/2020
The OIG recommended the Assistant Secretary for Information and Technology in coordination with the Assistant Secretary for Human Resources and Administration/Operations, Security, and Preparedness ensure an Information Security Officer is consistently responsible for the Report Exec system and properly notified.
Financial Controls and Payments Related to VA-Affiliated Nonprofit Corporations: Middle Tennessee Research Institute
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18-00711-106
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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: 5/13/2021
The VA Tennessee Valley Healthcare System (TVHS) director ensures the Middle Tennessee Research Institute’s Board of directors establishes procedures to verify adequate supporting documentation prior to approval of expenditures.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/13/2021
The OIG recommended that the VA Tennessee Valley Healthcare System (TVHS) director ensure the MTRI board of directors establishes procedures that require staff to verify supporting documentation before approving expenditures.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/13/2021
The OIG also recommended that the system director should establish procedures to ensure the R&D Budget Office supervisor conducts required periodic reviews of VA-affiliated nonprofit corporation invoices that staff have authorized for payment.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 1,900,000.00
Financial Controls and Payments Related to VA-Affiliated Nonprofit Corporations: Northern California Institute for Research and Education
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18-00711-141
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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: 5/13/2021
The San Francisco VA Healthcare System director establishes procedures to ensure the Research and Development Budget Office staff review VA-affiliated nonprofit corporation invoices to confirm services were performed or goods were received in accordance with Intergovernmental Personnel Act agreements before approving invoices for payment.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/24/2021
The San Francisco VA Healthcare System director establishes procedures to ensure the Research and Development Budget Office supervisor conducts periodic reviews of the VA-affiliated nonprofit corporation invoices authorized for payment by staff as required by VA Financial Policies and Procedures, Volume VIII, Chapter 1A.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 25,940,000.00
Deficiencies in Nursing Care and Management in the Community Living Center at the Coatesville VA Medical Center, Pennsylvania
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19-06391-119
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Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/3/2021
The Coatesville VA Medical Center Director reviews and monitors staff compliance with the Community Living Center required nursing processes and documentation for medication administration, pain management assessments, and care plans.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/3/2021
The Coatesville VA Medical Center Director examines Community Living Center nursing processes and ensures that required documentation for fall prevention assessments, which include measures such as bed positions, call bell access, and post-fall assessments, is completed and monitored.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/10/2021
The Coatesville VA Medical Center Director reviews and monitors staff compliance with Community Living Center call bell processes and practices.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/9/2021
The Coatesville VA Medical Center Director evaluates Community Living Center wound prevention processes and ensures that required wound documentation, including the measurement of patient weights and maintenance of skin integrity, is completed and monitored for compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/3/2021
The Coatesville VA Medical Center Director ensures that the newly developed Community Living Center hourly rounding form and process is approved in accordance with the facility’s standard operating procedure and aligns with the facility’s rounding policies, and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/11/2020
The Coatesville VA Medical Center Director makes sure that the fact-finding review process includes tracking and documenting issues through resolution and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/10/2021
The Coatesville VA Medical Center Director ensures that the Executive Leadership Board and the Geriatric and Extended Care Executive Council review, document, and track identified facility issues and, for the Executive Leadership Board, recommendations through resolution.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/10/2021
The Coatesville VA Medical Center Director reviews and monitors the maintenance and functionality of essential safety equipment on Community Living Center units.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/11/2020
The Coatesville VA Medical Center Director updates the facility staffing methodology policy and staffing methodology calculations to comply with current Veterans Health Administration staffing methodology requirements.
Coordination of Care and Employee Satisfaction Concerns at the Community Living Center, Loch Raven VA Medical Center, in Baltimore, Maryland
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19-08857-171
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Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/25/2021
The VA Maryland Health Care System Director conducts a comprehensive evaluation of the organizational health to include staff reporting of concerns and employee satisfaction at the Loch Raven Community Living Center, develops an action plan for improvement, and monitors progress.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2021
The VA Maryland Health Care System Director reviews current laboratory specimen handling procedures at the Loch Raven Community Living Center and implements an action plan to address identified deficiencies.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/21/2021
The VA Maryland Health Care System Director ensures that concerns reported to Pathology &Laboratory Medicine Service are investigated and that action plans are instituted as needed.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/21/2021
The VA Maryland Health Care System Director ensures Pathology & Laboratory Medicine Service staff notifies providers of critical laboratory results, documents in accordance with policy, and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/9/2021
The VA Maryland Health Care System Director reviews the current process for medication delivery, to include the effectiveness of recently initiated actions as described in the report, from the Baltimore VA Medical Center pharmacy to the Loch Raven Community Living Center and implements an action plan to address identified vulnerabilities.
Disability Compensation Benefit Adjustments for Hospitalization Need Improvement
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19-06249-94

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/28/2021
The OIG recommended the under secretary for benefits correct disability compensation benefits for the veterans identified in the sample whose benefits were not adjusted or were incorrectly adjusted.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/2/2020
The OIG recommended the under secretary for benefits develop and implement a plan to ensure all VA regional offices generate and process the weekly Admission Report for Service Connected Veterans and maintain coordinators’ logs to complete required benefit adjustments.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/2/2020
The OIG recommended the under secretary for benefits continue to develop and implement a plan to nationally generate and process the Admission Report for Service Connected Veterans.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/2/2020
The OIG recommended the under secretary for benefits determine if a statutory or regulatory change is required to ensure lawful, consistent, and timely processing of benefits for veterans entitled to temporary increases of benefits to 100 percent.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/17/2020
The OIG recommended the under secretary for benefits develop and implement a plan to ensure staff receive refresher training when needed to properly process temporary disability compensation benefit adjustments for veterans hospitalized for more than 21 days that includes monitoring the effectiveness of the training.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/6/2021
The OIG recommended the under secretary for benefits develop a plan to determine which veterans required adjustment of compensation benefits for hospitalization for a service connected condition, using the Admission Report for Service Connected Veterans for fiscal years 2018 and 2019, and make the required adjustments.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 40,000,000.00
VA’s Implementation of the FITARA Chief Information Officer Authority Enhancements
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18-04800-122
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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: 12/14/2020
The OIG recommends the Chief of Staff for Veterans Affairs ensures the Chief Information Officer, in conjunction with VA administrations and program offices develop and implement policy to support the Federal Information Technology Acquisition Reform Act delegation process and submit a Chief Information Officer Assignment Plan for the Office of Management and Budget’s review and approval.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 12/14/2020
The OIG recommends the Chief of Staff for Veterans Affairs ensures the Chief Information Officer, in conjunction with VA administrations and program offices establish internal controls sufficient to ensure the Chief Information Officer or the appropriate delegate reviews and approves all information technology acquisitions, regardless of appropriation, and implement improved VA policies and procedures to reflect these business processes.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/9/2020
The OIG recommends the Chief of Staff for Veterans Affairs ensures the Chief Information Officer, in conjunction with VA administrations and program offices modify all VA policy and guidance regarding implementation of Federal Information Technology Acquisition Reform Act requirements to provide clear and consistent Information Technology acquisition processes across the department.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 12/14/2020
The OIG recommends the Chief of Staff for Veterans Affairs ensures the Chief Information Officer, in conjunction with VA administrations and program offices develop and implement agency wide information technology acquisition awareness and training programs to improve VA employees’ understanding of Federal Information Technology Acquisition Reform Act requirements and the Chief Information Officer’s authority to review and approval all information technology acquisitions.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 2/6/2023
The OIG recommends the Chief of Staff for Veterans Affairs ensures the Chief Information Officer, in conjunction with VA administration and staff offices revise VA Directive 6008 to clarify the Chief Information Officer’s authority and roles in the planning, programming, budgeting, and execution of all information technology resources.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 12/14/2020
The OIG recommends the Chief of Staff for Veterans Affairs ensures the Chief Information Officer, in conjunction with VA administration and staff offices develop and implement policies and procedures across all VA administration and staff offices to specifically identify and separate information resources from non-IT resources, regardless of funding appropriation.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 1/20/2022
The OIG recommends the Chief of Staff for Veterans Affairs ensures the Chief Information Officer, in conjunction with VA administration and staff offices establish policies and procedures for all VA administration and staff offices to work with the Chief Information Officer for planning, programming, budgeting, and execution of all information technology resources and to manage VA’s overall information technology portfolio with resources that effectively achieve program and business objectives.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 1/20/2022
The OIG recommends the Chief of Staff for Veterans Affairs ensures the Chief Information Officer, in conjunction with VA administration and staff offices establish and implement department-level information technology governance and oversight processes to ensure that the Chief Information Officer is a member of VA governance boards that inform decisions on all information technology resources across the agency, regardless of funding appropriation.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 12/14/2020
The OIG recommends the VA Assistant Secretary for Information and Technology fully develop and implement the Office of Information and Technology governance framework to ensure Federal Information Technology Acquisition Reform Act requirements are met.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 12/14/2020
The OIG recommends the VA Assistant Secretary for Information and Technology fully implement the functionality of the Office of Strategic Planning and Analysis to ensure Federal Information Technology Acquisition Reform Act compliance for information technology strategic planning.
Improvements Needed to Reduce Aging Infrastructure Risks at Northport VA Medical Center in New York
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19-07482-91
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Topics:  Maintenance and Construction

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/1/2020
Develop an oversight process that Northport VA Medical Center leaders can rely on to effectively develop, implement, and execute the master plan to reduce the footprint of the medical center and better manage the needs of its aging infrastructure.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/1/2020
Ensure the Northport VA Medical Center director defines a timeline for executing the master plan and communicates the objectives to stakeholders to (1) instill consistency between the master and the strategic capital investment plans and (2) execute the master plan in accordance with agreed upon milestones and available resources.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/1/2020
Make certain the Northport VA Medical Center director develops processes and procedures for submitting work orders, including making notifications when work orders are assigned and reviewing work orders for accuracy and consistency, to ensure the medical center’s engineering service is in the best position to prioritize work and manage its resources.
VA Improved the Transparency of Mandatory Staffing and Vacancy Data
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20-00541-149
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Topics:  Staffing

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 12/8/2020
The assistant secretary for human resources and administration/ operations, security, and preparedness should ensure VA time to hire percentages are reported using the Office of Personnel Management’s target as required by Section 505(a)(1)(D) of the MISSION Act.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 1/5/2021
The assistant secretary for human resources and administration/ operations, security, and preparedness should confer with the VA Office of General Counsel to ensure that changes to the reporting methodology comply with Section 505 of the MISSION Act.
Death of a Patient, Deficiencies in Domiciliary Safety and Security, and Inadequate Contractual Agreement at the VA Northeast Ohio Healthcare System in Cleveland
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19-07091-159
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Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/15/2020
The VA Northeast Ohio Healthcare System Director conducts a full review of the patient’s care, including electrocardiograms and methadone initiation, and considers whether an institutional disclosure is warranted.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/9/2021
The VA Northeast Ohio Healthcare System Director ensures that electrocardiograms are completed prior to and during methadone treatment in accordance with Veterans Health Administration Pharmacy Benefits Management Services recommendations.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/15/2020
The VA Northeast Ohio Healthcare System Director ensures that domiciliary leaders implement a process to monitor the integrity of Volunteers of America staff documentation including health and safety rounding sheets and additional documentation directly pertaining to patients’ health, safety, and security.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Asset Enterprise Management (OAEM)
Closure Date: 6/11/2020
The VA Office of Asset Enterprise Management Director ensures that the Residential Services Agreement includes references to the Services Provider Contract between CGA LSVA Residential, LLC and Volunteers of America.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Asset Enterprise Management (OAEM)
Closure Date: 6/11/2020
The VA Office of Asset Enterprise Management Director, in consultation with the VA Office of General Counsel, determines if the Residential Services Agreement and the new term agreement needs to be reformed, or whether new contracts should be executed that clearly define the rights and responsibilities of all parties with respect to domiciliary services.
Delays in Diagnosis and Treatment and Concerns of Medical Management and Transfer of Patients at the Fayetteville VA Medical Center, North Carolina
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19-08256-124
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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: 2/10/2021
The Fayetteville VA Medical Center Director ensures that ordering providers review, acknowledge, and document an action plan for abnormal laboratory results.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/8/2020
The Fayetteville VA Medical Center Director considers initiating an institutional disclosure for the failure of primary care provider 1’s clinical action and follow-up for Patient A’s abnormal test results and takes necessary actions.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/25/2024

The Fayetteville VA Medical Center Director ensures that facility Community Care staff process Community Care consults according to the Veterans Health Administration policy.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/8/2020
The Fayetteville VA Medical Center Director conducts a comprehensive review of Patient A’s and Patient B’s episode of care and takes action as indicated.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/26/2021
The Fayetteville VA Medical Center Director evaluates the facility’s treating capabilities, delineates the medical conditions appropriate for admission, and updates the Policy for Admission/Discharge/Care of Patients to Intensive Care Unit.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/26/2021
The Fayetteville VA Medical Center Director conducts an analysis of the inter-facility transfer process for patients in emergency situations, and develops and implements strategies and actions for improvement.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/8/2020
The Fayetteville VA Medical Center Director updates the Patient Transfer Coordination policy to include the improvements from the transfer process analysis.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/10/2021
The Fayetteville VA Medical Center Director makes certain that facility staff are trained on the updated Patient Transfer Coordination policy and emergency inter-facility transfer process for inpatients and monitors the process, including timeliness of transfers.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/8/2020
The Fayetteville VA Medical Center Director reviews Patient B’s emergency medical services’ 911 call cancellation, considers initiating institutional disclosure, and takes appropriate action as indicated.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/10/2021
The Fayetteville VA Medical Center Director ensures the Critical Care Committee thoroughly evaluates code blue events, identifies related performance and system issues, makes recommendations, and ensures actions are implemented.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/8/2020
The Fayetteville VA Medical Center Director makes certain that solo practitioners have the privilege-specific competency components of their focused and ongoing professional practice evaluations performed by another provider with similar training and privileges and monitors compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/10/2021
The Fayetteville VA Medical Center Director ensures inter-facility patient data is collected, analyzed and incorporated into the facility’s quality management program.
VA’s Compliance with the Improper Payments Elimination and Recovery Act for FY 2019
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19-09563-142
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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: 4/28/2021
The Executive in Charge, Veterans Health Administration, implement appropriate IPERA testing procedures to ensure evidence is sufficient to verify that services were received for the Purchased Long-Term Services and Supports program.
Critical Care Unit Staffing and Quality of Care Deficiencies at the Charlie Norwood VA Medical Center, Augusta, Georgia
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19-08296-118
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Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2021
The Charlie Norwood VA Medical Center Director ensures compliance with requirements outlined in Veterans Health Administration and Charlie Norwood VA Medical Center policy memorandums for the prevention and management of pressure injuries, including nursing documentation requirements.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2021
The Charlie Norwood VA Medical Center Director ensures Critical Care Unit nursing staff receive ongoing training to manage patients at risk for developing pressure injuries.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2021
The Charlie Norwood VA Medical Center Director evaluates tele-ICU services, and makes changes as needed to ensure cardiac-monitored patients receive safe care.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/3/2021
The Charlie Norwood VA Medical Center Director ensures that a review to evaluate the circumstances related to Patient 8’s respiratory care is conducted and takes action as indicated.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2021
The Charlie Norwood VA Medical Center Director reviews current practices related to sitter availability when a physician orders a 1:1 sitter for Critical Care Unit patients and takes action as indicated.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2021
The Charlie Norwood VA Medical Center Director reviews current practices related to Critical Care Unit nursing staff assignments and takes action as indicated to support safe patient care when intravenous medications that require frequent dose adjustments are prescribed.
Radiology Concerns at the VA Illiana Health Care System Danville, Illinois
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18-05350-135
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Topics:  Patient Safety ● Medical Staff Privileging Credentialing

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/2/2021
The Under Secretary for Health adopts the National Radiology Program Office established guidelines and confers with the National Radiology Program Office to develop and incorporate a risk stratification methodology of the random sample of imaging modalities reviewed, to better inform radiologists’ professional practice evaluations.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2020
The Veterans Integrated Service Network Director provides continued oversight of the National Teleradiology Program expanded review results, ensures an appropriate response from VA Illiana Health Care System, and takes actions, as indicated.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2020
The VA Illiana Health Care System Director verifies that appropriate patient follow-up occurs, disclosures are conducted for events that meet disclosure criteria, and compliance with Veterans Health Administration policy is monitored.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2020
The VA Illiana Health Care System Director ensures the Radiology Service follows VA Illiana Health Care System policy to develop and implement a quality assurance and performance plan and monitors for compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2020
The VA Illiana Health Care System Director considers following the National Guidelines for Radiology Professional Competency for radiologist competency reviews.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2020
The VA Illiana Health Care System Director evaluates the final findings of the National Teleradiology Program review to determine what additional steps are required, including large-scale disclosure and reporting to outside agencies.
Manipulation of Radiology Reports and Leadership Failures in the Medical Imaging Service at Clement J. Zablocki VA Medical Center in Milwaukee, Wisconsin
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18-06074-123
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Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2020
The Under Secretary for Health ensures that the planning and implementation of the new electronic health record includes a process for addenda insertion, deletion, and consistent formatting for radiology reports.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2020
The Under Secretary for Health reviews Veterans Health Administration policy related to management of health information in the electronic health record, evaluates the circumstances that led to the Division Manager’s decision to direct the deletion of a completed and verified imaging report, and takes action, as indicated.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/6/2020
The Clement J. Zablocki VA Medical Center Director ensures a review of the radiology report for the patient with conflicting imaging study results and confirms that the most accurate impression is evident in electronic health record.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/11/2020
The Veterans Integrated Service Network Director reviews access, management, and the Veterans Integrated Service Network oversight of the Clement J. Zablocki VA Medical Center picture archiving and communication system practices, and takes action to remedy issues identified during the review, as indicated.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/6/2020
The Clement J. Zablocki VA Medical Center Director reviews the oversight and management of the Medical Imaging Service, confers with human resources, makes recommendations for improvement as indicated, and monitors progress.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/6/2020
The Clement J. Zablocki VA Medical Center Director completes an evaluation of the Medical Imaging Service’s culture, morale, and team cohesion, develops an action plan for improvement, and monitors progress.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/6/2020
The Clement J. Zablocki VA Medical Center Director evaluates the need for Medical Imaging Service staff to receive training on workplace intimidation and the process for employee reporting of concerns, and takes actions, as indicated.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/6/2020
The Veterans Integrated Service Network Director makes certain that future hotline case referrals are investigated in accordance with Veterans Affairs policy related to Office of Inspector General Hotline complaint referrals, and provides oversight of facility responses.
Review of Access to Care and Capabilities during VA’s Transition to a New Electronic Health Record System at the Mann-Grandstaff VA Medical Center in Spokane, Washington
|
19-09447-136
|
Topics:  Electronic Health Records Modernization (EHRM) ● Community Care

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 Health Administration (VHA)
Closure Date: 3/12/2025

The Under Secretary for Health, in conjunction with the Office of Electronic Health Records Modernization, evaluates the impact of the new electronic health record implementation on productivity and provides operational guidance and required resources to facilities prior to go-live.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/8/2022
The Under Secretary for Health, in conjunction with the Office of Electronic Health Records Modernization, identifies the impact of the mitigation strategies on user and patient experience at go-live and takes action, as needed.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/13/2021
The Executive Director, Office of Electronic Health Records Modernization, in conjunction with the Under Secretary for Health, ensures that clear guidance is given to facility staff on what electronic health record capabilities will be available at go-live.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/12/2025

The Under Secretary for Health, in conjunction with the Office of Electronic Health Records Modernization, reevaluates the electronic health record modernization deployment timeline to minimize the number of required mitigation strategies at go-live.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/13/2021
The Veterans Integrated Service Network Director collaborates with facility leaders to implement VA-provided operational guidance and supports required resources needed throughout the transition to the new electronic health record system.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/16/2020
The Veterans Integrated Service Network Director ensures that positions required for the transition to the new electronic health record system are staffed and trained prior to go-live.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/22/2021
The Mann-Grandstaff VA Medical Center Director ensures that community care consults are managed through go-live to ensure accuracy, completeness, and to avoid the need for manual reentry after go-live.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/22/2021
The Mann-Grandstaff VA Medical Center Director ensures that patients receive medication refills in a timely manner throughout the transition to the new electronic health record system.
Deficiencies in Infrastructure Readiness for Deploying VA’s New Electronic Health Record System
|
19-08980-95
|
Topics:  Electronic Health Records Modernization (EHRM) ● System Development and Implementation

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/1/2020

Establish an infrastructure-readiness schedule for future deployment sites thatincorporates lessons learned from DoD.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/1/2020

Reassess the enterprise-wide deployment schedule to ensure projected milestones arerealistic and achievable, considering the time needed for facilities to completeinfrastructure upgrades.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2021

Implement tools to comprehensively monitor the status and progress of medical devicesat the enterprise level.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/16/2021

Standardize infrastructure requirements in conjunction with VHA and the OIT and ensurethose requirements are disseminated to all necessary staff.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/9/2022

Evaluate physical infrastructure for consistency with OEHRM requirements and monitorcompletion of those evaluations.

No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/12/2022

Fill infrastructure-readiness team vacancies until optimal staffing levels are attained.

No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/9/2022

Ensure physical security assessments are completed and addressed at future electronichealth record deployment sites.

No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/1/2020

Ensure all access points to physical infrastructure are secured and inaccessible tounauthorized individuals.

Federal Information Security Modernization Act Audit for Fiscal Year 2019
|
19-06935-96
|
Topics:  FISMA

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: 4/29/2021
We recommended the Assistant Secretary for Information and Technology consistently implement an improved continuous monitoring program in accordance with the NIST Risk Management Framework. Specifically, implement an independent security control assessment process to evaluate the effectiveness of security controls prior to granting authorization decisions. (This is a modified repeat recommendation from prior years.)
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/29/2021
We recommended the Assistant Secretary for Information and Technology implement improved mechanisms to ensure system stewards and information system security officers follow procedures for establishing, tracking, and updating Plans of Action and Milestones for all known risks and weaknesses including those identified during security control assessments. (This is a modified repeat recommendation from prior years.)
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/29/2021
We recommended the Assistant Secretary for Information and Technology implement controls to ensure that system stewards and responsible officials obtain appropriate documentation prior to closing 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: 4/29/2021
We recommended the Assistant Secretary for Information and Technology develop mechanisms to ensure system security plans reflect current operational environments, include an accurate status of the implementation of system security controls, and all applicable security controls are properly evaluated. (This is a repeat recommendation from prior years.)
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/29/2021
We recommended the Assistant Secretary for Information and Technology implement improved processes for reviewing and updating key security documents such as security plans and interconnection agreements on an annual basis and ensure the information accurately reflects the current environment. (This is a modified repeat recommendation from prior years.)
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/29/2021
We recommended the Assistant Secretary for Information and Technology implement improved processes to ensure compliance with VA password policy and security standards on domain controls, operating systems, databases, applications, and network devices. (This is a repeat recommendation from prior years.)
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/29/2021
We recommended the Assistant Secretary for Information and Technology implement periodic 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. 8
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/29/2021
We recommended the Assistant Secretary for Information and Technology enable system audit logs on all critical systems and platforms and conduct centralized reviews of security violations across the enterprise. (This is a repeat recommendation from prior years
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/29/2021
We recommended the Assistant Secretary for Information and Technology fully implement two-factor authentication to the extent feasible for all user accounts throughout the agency. (This is a repeat recommendation from prior years.)
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/29/2021
We recommended the Assistant Secretary 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 repeat recommendation from prior years.)
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/29/2021
We recommended the Assistant Secretary for Information and Technology implement a more effective patch and vulnerability management program to address security deficiencies identified during our assessments of VA’s web applications, database platforms, network infrastructure, and workstations. (This is a repeat recommendation from prior years.)
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/29/2021
We recommended the Assistant Secretary for Information and Technology maintain a complete and accurate security baseline configuration for all platforms and ensure all baselines are appropriately implemented for compliance with established VA security standards. (This is a repeat recommendation from prior years.)
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/29/2021
We recommended the Assistant Secretary for Information and Technology implement improved network access controls that restrict medical devices from systems hosted on the general network. (This is a modified repeat recommendation from prior years.)
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/29/2021
We recommended the Assistant Secretary for Information and Technology consolidate the security responsibilities for networks not managed by the Office of Information and Technology, under a common control for each site and ensure vulnerabilities are remediated in a timely manner. (This is a repeat recommendation from prior years.)
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/29/2021
We recommended the Assistant Secretary for Information and Technology implement improved processes to ensure that all devices and platforms are evaluated using credentialed vulnerability assessments. (This is a repeat recommendation from prior years.)
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/29/2021
We recommended the Assistant Secretary for Information and Technology implement improved procedures to enforce standardized system development and change control processes that integrates information security throughout the life cycle of each system. (This is a repeat recommendation from prior years.)
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/29/2021
We recommended the Assistant Secretary for Information and Technology review system boundaries, recovery priorities, system components, and system interdependencies and implement appropriate mechanisms to ensure that established system recovery objectives are met. (This is a modified repeat recommendation from prior years.)
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/29/2021
We recommended the Assistant Secretary for Information and Technology implement more effective agency-wide incident response procedures to ensure timely notification, reporting, updating, and resolution of computer security incidents in accordance with VA standards. (This is a repeat recommendation from prior years.)
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/29/2021
We recommended the Assistant Secretary for Information and Technology ensure that VA’s Cybersecurity Operations Center has full access to all security incident data to facilitate an agency-wide awareness of information security events. (This is a repeat recommendation from prior years.)
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/29/2021
We recommended the Assistant Secretary for Information and Technology implement improved safeguards to identify and prevent unauthorized vulnerability scans on VA networks. (This is a repeat recommendation from prior years.)
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/29/2021
We recommended the Assistant Secretary for Information and Technology implement improved measures to ensure that security control deficiencies are tracked individually instead of consolidating security deficiencies under one control. (This is a modified repeat recommendation from prior years.)
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/29/2021
We recommended the Assistant Secretary for Information and Technology fully develop a comprehensive list of approved and unapproved software and implement continuous monitoring processes to prevent the use of prohibited software on agency devices. (This is a repeat recommendation from prior years.)
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/29/2021
We recommended the Assistant Secretary for Information and Technology develop a comprehensive inventory process to identify connected hardware, software, and firmware used to support VA programs and operations. (This is a repeat recommendation from prior years.)
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/29/2021
We recommended the Assistant Secretary for Information and Technology implement improved procedures for monitoring contractor-managed systems and services and ensure information security controls adequately protect VA sensitive systems and data. (This is a modified repeat recommendation from prior years.)
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/29/2021
We recommended the Executive in Charge for Information and Technology ensure appropriate levels of background investigations be completed for all personnel in a timely manner, implement processes to monitor and ensure timely reinvestigations on all applicable employees and contractors, and monitor the status of the requested investigations.
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