All Reports

Comprehensive Healthcare Inspection of the Oscar G. Johnson VA Medical Center, Iron Mountain, Michigan
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18-04669-125

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/28/2020
The chief of staff ensures that managers consistently implement improvement actions recommended from peer review activities and then monitors the managers’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2020
The chief of staff makes certain that all required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors the representatives’ compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/1/2019
The chief of staff ensures that clinical managers clearly define and share in advance the expectations and outcomes for focused professional practice evaluations for cause with providers and monitors the clinical managers’ compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/16/2020
The chief of staff ensures providers complete initial evaluations within the required timeframe for all new patients referred for mental health services for military sexual trauma and monitors the providers’ compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/10/2020
The chief of staff makes certain that clinicians provide and document patient and/or caregiver education about the potential interactions and side effects of newly prescribed medications and monitors the clinicians’ compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/28/2020
The chief of staff ensures clinicians reconcile medication information and maintain and communicate accurate patient medication information in patients’ electronic health record and monitors the clinicians’ compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/28/2020
The facility director confirms that the Women Veterans Health Committee includes required core members and monitors the committee’s compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/1/2019
The facility director makes certain that the urgent care center is staffed with registered nurses in accordance with VHA policy at all times of operation and monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2020
The chief of staff ensures that a backup call schedule is maintained for urgent care center providers and monitors compliance.
Decision Ready Claims Program Hindered by Ineffective Planning
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18-05130-105

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No. 1
Not Implemented Recommendation Image, X character'
to Veterans Benefits Administration (VBA)
Closure Date: 5/21/2019
The Under Secretary for Benefits works with the VA Secretary and Chief Financial Officer to take steps required by OMB Circular A-11 to determine whether an Antideficiency Act violation occurred and, if so, take appropriate action for funds already obligated and expended for medical examinations under the Decision Ready Claims program.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 10,572,000.00
Deferrals in the Veterans Benefits Management System
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18-00215-83

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/15/2019
The Under Secretary for Benefits implement plans to enhance quality assurance by conducting periodic national oversight of deferrals and ensuring local oversight specifically addresses all aspects of the accuracy of deferrals created in the Veterans Benefits Management System.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/15/2019
The Under Secretary for Benefits establish internal controls documenting Rating Veterans Service Representatives are informed of their mitigated deferrals and corrective action is taken.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/19/2021
The Under Secretary for Benefits update guidance to clarify why certain reason selections should be made for deferrals, provide training on this guidance, and monitor the effectiveness of the training.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/29/2021
The Under Secretary for Benefits establish plans to modify the Veterans Benefits Management System to allow sufficient space for inputting deferral instructions and require claims processors to input references when creating deferrals.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 1,100,000.00
Inpatient Mental Health Clinical Operations Concerns at the Phoenix VA Health Care System, Arizona
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17-02629-119

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/21/2020
The Phoenix VA Health Care System Director verifies that clinicians document clinical justification for the continued use of restraints and debriefing sessions according to Veterans Health Administration and Phoenix VA Health Care System policy requirements.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/7/2019
The Phoenix VA Health Care System Director makes certain that the Phoenix VA Health Care Patient Safety Observer policy is followed, and compliance is monitored.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/7/2019
The Phoenix VA Health Care System, Director ensures that inpatient mental health unit nurse staffing methodology is conducted as required by Nurse Staffing Methodology for Veterans Health Administration Nursing Personnel Directive.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/4/2020
The Phoenix VA Health Care System, Director confirms that mental health staff receive mandated training at required intervals including training for patients with dementia as appropriate, and compliance is monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/7/2019
The Phoenix VA Health Care System Director verifies that the inpatient mental health unit is cleaned on a regular basis and compliance is monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/21/2020
The Phoenix VA Health Care System Director ensures that the environment on the inpatient mental health unit is a home-like therapeutic setting as required by Veterans Health Administration Inpatient Mental Health Services Handbook.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/7/2019
The Phoenix VA Health Care System Director ensures that Phoenix VA Health Care System staff enter complaints into the Patient Advocate Tracking System consistent with current Veterans Health Administration Patient Advocacy Program and facility policies and compliance is monitored.
Orthopedic Surgery Department and Other Concerns at the Carl T. Hayden VAMC, Phoenix, Arizona
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18-02493-122

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/21/2019
The Carl T. Hayden VA Medical Center Director conducts comprehensive reviews of all aspects of decision-making and care provided to Patient Red and Patient Blue, and takes action, as appropriate.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/21/2019
The Carl T. Hayden VA Medical Center Director considers conducting an institutional disclosure in Patient Red’s case, and takes action as appropriate.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/21/2019
The Carl T. Hayden VA Medical Center Director continues efforts to assess and improve inefficiencies, including on-call surgeon accountability issues, within the Orthopedic Surgery Department.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/30/2020
The Carl T. Hayden VA Medical Center Director takes appropriate action relative to the letter of expectation issued to the Chief of Orthopedic Surgery Department.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/21/2019
The Carl T. Hayden VA Medical Center Director addresses inter-departmental communication, collaboration, and problem-solving challenges as discussed in this report.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/21/2019
The Carl T. Hayden VA Medical Center Director follows up on consultative recommendations made by the anesthesia and operating room site visit team.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/21/2019
The Carl T. Hayden VA Medical Center Director evaluates the adequacy of Sterile Processing Services space and the loaner instrument policy, and takes action as appropriate.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/21/2019
The Carl T. Hayden VA Medical Center Director assesses the feasibility of implementing an electronic instrument tracking system within Sterile Processing Services, and takes actions as appropriate.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/30/2020
The Carl T. Hayden VA Medical Center Director revises the orthopedic surgery core privileges description to accurately reflect procedures performed at the Carl T. Hayden VA Medical Center.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/21/2020
The Carl T. Hayden VA Medical Center Director ensures appropriate data collection, analysis, and reporting for orthopedic providers’ ongoing professional practice evaluations.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/21/2019
The Carl T. Hayden VA Medical Center Director develops a physician assistant utilization policy as required by Veterans Health Administration.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/30/2020
The Carl T. Hayden VA Medical Center Director updates physician assistant scopes of practice to fully reflect the activities and listing of surgical first assist responsibilities for individual orthopedic physician assistants.
Staffing, Quality of Care, Supplies, and Care Coordination Concerns at the VA Loma Linda Healthcare System, California
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17-02186-114

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/15/2020
The VA Loma Linda Healthcare System Director defines goals, implements measures, and monitors outcomes to improve the flow of patients throughout the hospital, including the Emergency Department, inpatient medical and surgical units, mental health units, and the Community Living Center.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/24/2020
The VA Loma Linda Healthcare System Director conducts a review to evaluate the accuracy of data entered in Emergency Department Integration Software and takes action to ensure that the data collection tool may be used for operational improvement.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/15/2020
The VA Loma Linda Healthcare System Director ensures that patients admitted to a unit where there is no bed available receive the same level of care that is provided in the unit to which they are assigned.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/24/2020
The VA Loma Linda Healthcare System Director ensures that bed closures are reported to the Veterans Integrated Service Network as required by VA Loma Linda Healthcare System policy.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/29/2020
The VA Loma Linda Healthcare System Director evaluates the care of patients with sepsis in the Emergency Department, identifies opportunities for improvement, and takes actions to improve care.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/24/2020
The VA Loma Linda Healthcare System Director evaluates the response time of psychiatrists consulted for the care of mental health patients in the Emergency Department and takes action if required.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/15/2019
The VA Loma Linda Healthcare System Director conducts an evaluation of Patient C’s 2016 coordination of care, discharge planning, and transfer of care, including but not limited to, conferring with the Director of the Robley Rex Veterans Affairs Medical Center, Louisville, Kentucky, and takes action as necessary.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/15/2020
The VA Loma Linda Healthcare System evaluates, develops, and implements processes for veterans who have anticipated or unexpected medical needs coordinated by their preferred medical facility and an alternate medical facility.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/15/2019
The VA Loma Linda Healthcare System Director evaluates and ensures that root cause analyses are completed in accordance with Veterans Health Administration directives.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/16/2020
The VA Loma Linda Healthcare System Director reviews the care of the two fall patients with injuries discussed in this report, adheres to Veterans Health Administration policies, and takes action as appropriate.
Improper Coding and Unnecessary Overtime at the Central Texas Veterans Health Care System
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18-03159-74

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/16/2019
The Central Texas Veterans Health Care System Director ensures all psychologists are properly trained on coding.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/16/2019
The Central Texas Veterans Health Care System Director instructs the Chief of Psychology to review care provider coding accuracy in routine evaluations.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/16/2019
The Central Texas Veterans Health Care System Director makes certain the Chief of Health Information Management performs annual reviews of provider coding as specified in VHA policy.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/16/2019
The Central Texas Veterans Health Care System Director confirms that the Chief and Assistant Chief of Medical Administration Service, along with the Compliance Officer, provide adequate oversight of the Health Information Management provider coding reviews.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/16/2019
The Central Texas Veterans Health Care System Director ensures clinic hours are sufficiently scheduled to maximize direct patient care and to achieve targeted productivity.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/16/2019
The Central Texas Veterans Health Care System Director makes certain that all telehealth clinics follow VHA’s scheduling policies by using the approved electronic scheduling system and assigns properly trained telehealth schedulers.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/16/2019
The Central Texas Veterans Health Care System Director oversees proper disposal of the paper planner and secures patient information.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/16/2019
The Central Texas Veterans Health Care System Director makes certain the Chief of Psychology determines, before authorizing overtime, whether the requested services could be performed during normal working hours.
Expendable Inventory Management System: Oversight of Migration from Catamaran to the Generic Inventory Package
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17-05246-98

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/31/2019
The Executive in Charge, Office of the Under Secretary for Health, implements controls to ensure VA medical centers comply with policy to accurately annotate distribution of supply items.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2020
The Executive in Charge, Office of the Under Secretary for Health, implements controls to ensure VA medical centers comply with policy to make supply logs available, include all required elements, and are used by VA medical center staff.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/1/2021
The Executive in Charge, Office of the Under Secretary for Health, strengthens procedures for VA medical centers to sufficiently conduct and document physical inventory results and retain documentation as required by VHA policy.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/1/2021
The Executive in Charge, Office of the Under Secretary for Health, strengthens controls at VA medical centers to ensure supplies are consistently secured.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/1/2021
The Executive in Charge, Office of the Under Secretary for Health, ensures VA medical centers affix barcode labels for all expendable supplies at the locations where the inventory items are stored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/1/2021
The Executive in Charge, Office of the Under Secretary for Health, strengthens procedures for the Veteran Integrated Service Network Quality Control Review process, ensuring a thorough review is conducted and action plans are developed and executed to address identified deficiencies at the VAMCs. In addition, update the Quality Control Review document regarding VA medical center security, access requirements, and improper distribution of supplies.
Quality and Coordination of a Patient’s Care at the VA Eastern Colorado Health Care System, Denver, Colorado
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18-01455-108

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/9/2020
The VA Eastern Colorado Health Care System Director confirms that providers who perform patients’ clinical histories complete medication reconciliation to include non-VA medications.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/25/2019
The VA Eastern Colorado Health Care System Director confirms that healthcare providers further evaluate patients when indicators of infection are present, including rising white blood cell counts, and that providers take action as appropriate.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/5/2019
The VA Eastern Colorado Health Care System Director ensures that patient care teams verify that resources needed upon discharge, including family assistance, are available and meets patients’ needs.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/28/2020
The VA Eastern Colorado Health Care System Director strengthens processes and documentation that is consistent with Veterans Health Administration Directive 1140.11 when elderly patients are transitioning in care.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/27/2020
The VA Eastern Colorado Health Care System Director conducts a review of the interdisciplinary discharge planning team notes and patient discharge orders to identify and correct provider to patient communication deficiencies, and if deficiencies are noted, develop action plans to rectify the communication and mitigation issues identified.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/5/2019
The VA Eastern Colorado Health Care System Director verifies that outpatient podiatry scheduling practices align with Veterans Health Administration and VA Eastern Colorado Health Care System podiatry scheduling policies and takes action as necessary.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/5/2019
The VA Eastern Colorado Health Care System Director verifies that Wound Care Clinic practice aligns with VA Eastern Colorado Health Care System policy and takes action as necessary.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/5/2019
The VA Eastern Colorado Health Care System Director ensures that a review is conducted of podiatry resident supervision and develop and implement corrective action plans with timelines and oversight of podiatry residency program as necessary.
Review of Hepatitis C Virus Care within the Veterans Health Administration
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17-05297-85

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2019
The Under Secretary for Health ensures that patients with confirmed positive chronic hepatitis C infection have provider documentation to address treatment considerations entered in their EHRs.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2019
The Under Secretary for Health ensures that providers obtain posttreatment hepatitis C RNA tests to evaluate patient response to DAA treatment in alignment with VA National Viral Hepatitis Program Guidelines.
Federal Information Security Modernization Act Audit for Fiscal Year 2018
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18-02127-64

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/31/2020
We recommended the Executive in Charge for Information and Technology consistently implement the agency-wide risk management governance structure, along with mechanisms to identify, monitor, and manage risks across the enterprise. (This is a modified repeat recommendation from prior years.)
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/31/2020
We recommended the Executive in Charge for Information and Technology implement mechanisms to ensure sufficient supporting documentation is captured to justify closure of Plans of Action and Milestones. (This is a repeat recommendation from prior years.)
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/31/2020
We recommended the Executive in Charge for Information and Technology implement improved processes to ensure that all identified weaknesses are incorporated into the Governance Risk and Compliance tool in a timely manner, and corresponding Plans of Action and Milestones are developed to track corrective actions and remediation. (This is arepeat recommendation from prior years.)
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/31/2020
We recommended the Executive in Charge for Information and Technology implement clear roles, responsibilities, and accountability for developing, maintaining, completing, and reporting on Plans of Action and Milestones. (This is a repeat recommendation from prioryears.)
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/31/2020
We recommended the Executive in Charge 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. 6
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/31/2020
We recommended the Executive in Charge for Information and Technology implement improved processes for reviewing and updating key security documents such as security plans and security control assessments on an annual basis and ensure the information accurately reflects the current environment. (This is a modified repeat recommendation from prior years.)
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/31/2020
We recommended the Executive in Charge for Information and Technology implement mechanisms to enforce VA password policies and standards on all operating systems, databases, applications, and network devices. (This is a repeat recommendation from prioryears.)
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/31/2020
We recommended the Executive in Charge 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 repeatrecommendation from prior years.)
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/31/2020
We recommended the Executive in Charge 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. 10
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/31/2020
We recommended the Executive in Charge for Information and Technology fully implement two-factor authentication to the extent feasible for all user accounts throughout the agency. (This is a modified repeat recommendation from prior years.)
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/31/2020
We recommended the Executive in Charge for Information and Technology implement more effective automated mechanisms to continuously identify and remediate security deficiencies on VA’s network infrastructure, database platforms, and web application servers. (This is a repeat recommendation from prior years.)
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/31/2020
We recommended the Executive in Charge for Information and Technology implement a more effective patch and vulnerability management program to address security deficiencies identified during our assessments of VA’s web applications, database platforms, network infrastructure, and workstations. (This is a repeat recommendation from prior years.)
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/31/2020
We recommended the Executive in Charge 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. 14
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/31/2020
We recommended the Executive in Charge for Information and Technology implement improved network access controls to restrict medical devices from the general network and ensure that databases, file shares, and management devices, are adequately secured prior to connecting to VA’s network. (This is a modified repeat recommendation from prior years.)
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/31/2020
We recommended the Executive in Charge for Information and Technology consolidate thesecurity 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. 16
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/31/2020
We recommended the Executive in Charge 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. 17
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/31/2020
We recommended the Executive in Charge for Information and Technology implement improved procedures to enforce a standardized system development and change control framework that integrates information security throughout the life cycle of each system. (Thisis a repeat recommendation from prior years.)
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/31/2020
We recommended the Executive in Charge for Information and Technology implement improved processes for ensuring that backup data is adequately secured in accordance with organizational policy. (This is a repeat recommendation from prior years.)
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/31/2020
We recommended the Executive in Charge for Information and Technology implement improved processes for the review of system outages and disruptions for contingency plan improvements in accordance with defined policy. (This is a modified repeat recommendationfrom prior years.)
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/31/2020
We recommended the Executive in Charge for Information and Technology identify all external network interconnections and implement improved processes for monitoring VA networks, systems, and connections for unauthorized activity. (This is a repeatrecommendation from prior years.)
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/31/2020
We recommended the Executive in Charge for Information and Technology implement more effective agency-wide incident response procedures to ensure timely reporting, updating, and resolution of computer security incidents in accordance with VA standards. (This is arepeat recommendation from prior years.)
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/31/2020
We recommended the Executive in Charge for Information and Technology ensure that VA’s Cybersecurity Operations Center has full access to all security incident data to facilitate anagency-wide awareness of information security events. (This is a repeat recommendationfrom prior years.)
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/31/2020
We recommended the Executive in Charge for Information and Technology implement improved safeguards to identify and prevent unauthorized vulnerability scans on VA networks. (This is a modified repeat recommendation from prior years.)
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/31/2020
We recommended the Executive in Charge 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 amodified repeat recommendation from prior years.)
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/31/2020
We recommended the Executive in Charge 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 modified repeat recommendationfrom prior years.)
No. 26
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/31/2020
We recommended the Executive in Charge for Information and Technology implement improved procedures for overseeing contractor-managed systems and ensure information security controls adequately protect VA sensitive systems and data. (This is a modified repeat recommendation from prior years.)
No. 27
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/31/2020
We recommended the Executive in Charge for Information and Technology implement mechanisms for updating their systems inventory, including contractor-managed systems and interfaces, and provide this information in accordance with Federal reporting requirements. (This is a repeat recommendation from prior years.)
No. 28
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/31/2020
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.
Delayed Radiology Test Reporting at the Dwight D. Eisenhower VA Medical Center, Leavenworth, Kansas (VA Eastern Kansas Health Care System)
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18-00980-84

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: 7/15/2019
The VA Eastern Kansas Health Care System Director ensures providers communicate abnormal test results to patients and update the VA Eastern Kansas Health Care System policy in accordance with Veterans Health Administration Directive 1088 and monitors for compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/15/2019
The VA Eastern Kansas Health Care System Director ensures radiologists receive training for the national diagnostic codes and the software that triggers view alerts.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/15/2019
The VA Eastern Kansas Health Care System Director ensures that peer reviews are initiated in accordance with Veterans Health Administration Directive 2010-025 and monitors for compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/15/2019
The VA Eastern Kansas Health Care System Director ensures that an administrative investigation of the primary care provider involved in the patient’s care is conducted in accordance with VA Handbook 0700 and takes any action necessary.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/15/2019
The VA Eastern Kansas Health Care System Director considers initiating an institutional disclosure consistent with Veterans Health Administration Directive 1004.08 and takes action as necessary.
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