Recommendations
2124
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 25-00529-219 | Audit of Integrated Financial and Acquisition Management System Access Controls | Audit | ||
1 Implement a plan with the Office of Acquisition and Logistics Project Management Office to ensure system access is more granular and the intent of the principle of least privilege is met.
2 Ensure all roles and accesses, including those provided by default access, are reviewed and certified periodically as required.
3 Implement a permanent solution to provide supervisors and information owners with visibility of all roles and accesses, including those provided by default access, granted to users.
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| 25-00214-61 | Healthcare Facility Inspection of the VA Central California Health Care System in Fresno | Healthcare Facility Inspection | ||
1 The Executive Director ensures staff receive education about badge holders’ responsibilities in preventing unauthorized access to VA facilities and computer systems and safeguarding electronic databases including electronic health care records.
2 The Executive Director ensures signs are present and accurate throughout the facility.
Closure Date:
3 The Executive Director ensures staff maintain privacy curtains, preventive maintenance on medical equipment, and splash resistant bottom shelves on supply carts.
Closure Date:
4 The Executive Director ensures staff monitor patient care areas for expired, damaged, and contaminated medications and remove them as needed.
5 The Executive Director ensures staff store medications in pharmaceutical grade refrigerators.
6 The Executive Director ensures primary care staffing is sufficient for patients to receive appropriate health care.
7 The Executive Director reviews staffing levels for the Housing and Urban Development–Veterans Affairs Supportive Housing program and takes action as needed.
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| 25-00243-56 | Healthcare Facility Inspection of the VA Sierra Nevada Health Care System in Reno | Healthcare Facility Inspection | ||
1 The Medical Center Director ensures staff properly store clean medical equipment.
2 Facility leaders develop written workflows for each service to ensure timely communication of test results to providers and patients.
Closure Date:
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| 25-00238-44 | Healthcare Facility Inspection of the VA Battle Creek Healthcare System in Michigan | Healthcare Facility Inspection | ||
1 The Director ensures staff keep the environment clean and safe.
Closure Date:
2 The Director ensures Healthcare Technology Management Service staff inspect, test, and properly document all medical equipment maintenance per their required schedule.
Closure Date:
3 The Director ensures staff implement processes to prevent repeat environment of care findings identified in this report.
Closure Date:
4 Facility leaders ensure service-level workflows include each staff member’s role in the communication of test results process.
Closure Date:
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| 25-00207-36 | Healthcare Facility Inspection of the VA Indiana Healthcare System in Indianapolis | Healthcare Facility Inspection | ||
1 The Assistant Director ensures staff maintain a consistently clean environment throughout the facility to prevent repeat environment of care findings.
2 Executive leaders review the change in laboratory scheduling practices and minimize its effect on clinic efficiency.
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| 25-00215-32 | Healthcare Facility Inspection of the VA Southern Nevada Healthcare System in North Las Vegas | Healthcare Facility Inspection | ||
1 The Executive Director ensures staff consistently label reusable medical equipment to show it is clean and ready for use.
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| 24-00568-38 | Review of Data Security and Oversight Processes of a Veterans Health Administration National Cancer Prevention, Treatment, and Research Program | National Healthcare Review | ||
1 The Executive Director of Operations for a national cancer testing program ensures the project has met the requirements for Institutional Review Board review for research with human subjects and takes action as needed.
2 The Executive Director of Operations for a national cancer testing program ensures national cancer prevention, treatment, and research program staff are trained on Institutional Review Board project submission and privacy requirements.
3 The National Specialty Care Program Office Chief Officer ensures the national cancer prevention, treatment, and research program staff reviews and provides required approvals before the release of protected health information for research.
4 The National Specialty Care Program Office Chief Officer, in conjunction with the Office of Research & Development ensures that VA privacy officers report privacy incidents involving data obtained from or for national cancer prevention, treatment, and research program activities timely and monitors for compliance.
5 The Office of Research Oversight Executive Director in conjunction with the Chief Research and Development Officer, VHA Office of Research & Development, reviews the national cancer prevention, treatment, and research program final mitigation plan and ensures corrective actions address system-wide issues for determining whether a national cancer prevention, treatment, and research program project constitutes research, safeguarding privacy when data is shared for projects, and ensuring data security requirements are met.
6 The National Specialty Care Program Office Chief Officer ensures the national cancer prevention, treatment, and research program has safeguards in place including biostatistician expertise to ensure that data containing sensitive patient information and protected health information is deidentified before sharing outside of VA as required.
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| 24-03708-141 | Follow-Up Inspection of Information Security at the VA Beckley Healthcare System in West Virginia | Information Security Inspection | ||
1 Implement vulnerability management processes to ensure all vulnerabilities are identified and plans of action and milestones are created for vulnerabilities that cannot be mitigated by VA deadlines.
2 Develop and approve an authorization to operate for the special-purpose systems.
Closure Date:
3 Include facility personnel during the security categorization process to ensure all necessary information types are considered when determining the security categorization for special-purpose systems.
Closure Date:
4 Segregate the pharmacy application administrative access from individuals who are custodians of the pharmaceutical inventory.
Closure Date:
5 Ensure a witness observes the destruction of temporary paper files that contain personally identifiable information and protected health information.
Closure Date:
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| 24-03419-34 | Healthcare Facility Inspection of the VA Central Alabama Health Care System in Montgomery | Healthcare Facility Inspection | ||
1 Facility leaders install detectable warning surfaces where crosswalks transition onto a vehicle roadway.
2 Facility leaders ensure clinical staff who perform toxic exposure screenings complete mandatory training.
3 The Director ensures staff implement processes to prevent repeat environment of care findings related to dusty sprinkler heads.
4 Facility leaders evaluate all areas where biohazardous materials are located to ensure staff store clean and dirty items separately.
5 The Director ensures staff keep the environment clean and safe.
6 Facility leaders ensure their policy aligns with VHA Directive 1088(1) and develop workflows for all services that communicate test results to patients.
7 The Chief of Staff and Associate Director for Patient Care Services ensure corrective actions address unfavorable trends in communication of test result data.
8 The Director ensures the Chief of Staff chairs and attends the Peer Review Committee meetings as required by VHA.
9 The Director ensures patient safety managers identify adverse events as sentinel events when they meet criteria.
10 Facility leaders evaluate and improve processes to identify adverse events that warrant an institutional disclosure.
11 The Director implements processes to ensure staff track action plans until they are completed and report to leaders those that are outstanding.
12 The Director ensures leaders train staff on their roles and responsibilities when responding to a medical emergency, including the location of equipment used for medical emergencies.
Closure Date:
13 The Director ensures leaders revise the emergency response policy based on recertification time frames in VHA Directive 0999(1) or sooner, if warranted.
14 Facility leaders ensure all applicable staff maintain basic life support certification and take appropriate action for those staff without it.
15 The Director ensures facility leaders manage primary care teams’ panel sizes to support patients’ access to care.
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| 24-02347-40 | Review of Veterans Integrated Service Network 7 Leaders’ Effectiveness in Resolving Operational and Leadership Challenges at the VA Dublin Healthcare System in Georgia | Hotline Healthcare Inspection | ||
1 The Veterans Integrated Service Network Director develops and implements a plan to provide sustained support and oversight in a constructive manner to the VA Dublin Healthcare System leaders and programs.
2 The Veterans Integrated Service Network Director ensures that following Veterans Integrated Service Network site reviews with findings, Veterans Integrated Service Network staff review the associated VA Dublin Healthcare System action plans to confirm proposed actions adequately address findings, track action items through implementation, evaluate effectiveness to ensure resolution, and monitor for sustainment.
3 The Under Secretary for Health considers standardizing the Veterans Integrated Service Network Chief Medical Officer’s and Chief Nursing Officer’s role and responsibilities to include the authority to hold systems leaders accountable for resolving identified deficiencies.
Closure Date:
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15303