Recommendations
2056
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 23-00547-187 | VBA Did Not Ensure Employees Sent Some Letters Using Its Package Manager Application | Review | ||
1 Implement and periodically monitor the effectiveness of a plan to provide oversight for unsent packages in the Package Manager application.
2 Implement a plan to address existing unsent packages in the Package Manager application.
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| 24-01232-02 | Inspection of Information Security at the Health Eligibility Center in Atlanta, Georgia | Information Security Inspection | ||
1 Improve vulnerability management processes to ensure all vulnerabilities are identified and that plans of action and milestones are created for vulnerabilities that cannot be mitigated by VA deadlines.
2 Implement a more effective system life-cycle process to ensure network devices are running authorized software and operating systems that are configured to approved baselines and free of vulnerabilities.
Closure Date:
3 Ensure all file systems holding veteran information are encrypted in accordance with NIST and VA policy requirements.
Closure Date:
4 Maintain an accurate inventory of personnel with key access to the facility.
Closure Date:
5 Enable improved audit logging capability to monitor administrator access to sensitive information hosted on the Workload Reporting and Productivity Assessing file server.
Closure Date:
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| 23-03526-07 | Heart Transplant Program Review: Facility Leaders Failed to Ensure a Culture of Safety and the Section Chief Engaged in Unprofessional Conduct at the Richmond VA Medical Center in Virginia | Hotline Healthcare Inspection | ||
1 The Richmond VA Medical Center Director ensures completion of a clinical review of patient 2’s cardiothoracic surgical episode of care and takes action as appropriate.
Closure Date:
2 The Under Secretary for Health ensures that consideration to reactivate the heart transplant program at the Richmond VA Medical Center includes a comprehensive analysis of transplant referral volume, leadership competency, and transplant team proficiency.
3 The Under Secretary for Health ensures that VA Mid-Atlantic Health Care Network and Richmond VA Medical Center leaders conduct a rigorous surveillance of quality measures if the heart transplant program is reactivated and emphasize safely meeting program target volumes to maintain clinical experience.
4 The Richmond VA Medical Center Director ensures the chief of surgery conducts a review of the cardiothoracic section chief’s unprofessional behaviors and develops a plan to address complaints.
Closure Date:
5 The Richmond VA Medical Center Director ensures surgical leaders review cardiothoracic staff’s concerns and take action to create a culture of safety, and considers the use of resources such as the National Center for Organization Development.
Closure Date:
6 The VA Mid-Atlantic Health Care Network Director develops a process for ensuring VA Mid-Atlantic Health Care Network staff provide timely and complete responses to facility leaders’ requests for clinical care reviews.
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| 23-02890-209 | VBA’s and NCA’s Personnel Suitability Programs Need Improved Governance | Audit | ||
1 Execute the compliance plan for the Veterans Benefits Administration’s personnel suitability program.
Closure Date:
2 Ensure the Veteran Benefits Administration’s personnel suitability program oversight verifies background investigations are initiated and adjudicated within prescribed timelines and that documentation is filed as required.
Closure Date:
3 Establish a plan to ensure robust oversight of the National Cemetery Administration’s personnel suitability program that includes verifying background investigations are initiated and adjudicated within prescribed timelines and that documentation is filed as required.
Closure Date:
4 Evaluate resource requirements for the personnel suitability program to ensure that all personnel suitability requirements are being met.
Closure Date:
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| 24-00386-265 | Inspection of Select Vet Centers in Pacific District 5 Zone 1 | Vet Center Inspection Program | ||
1 District leaders and the Everett and Walla Walla Vet Center Directors collaborate with the support VA medical facility to determine reasons for noncompliance with staff participation on the mental health executive council, take action as indicated, and monitor compliance.
Closure Date:
2 District leaders and the Eugene Vet Center Director determine reasons for noncompliance with completing four hours of external clinical consultation for clinically complex cases per month, ensure a process is implemented, and monitor compliance.
Closure Date:
3 District leaders and the Anchorage, Eugene, and Everett Vet Center Directors determine reasons for noncompliance with employees completing select trainings in the required time frame, ensure completion, and monitor compliance.
Closure Date:
4 District leaders and the Anchorage, Eugene, Everett, and Walla Walla Vet Center Directors determine reasons for noncompliance with completion of an outreach plan with all required strategic components, ensure completion, and monitor compliance.
Closure Date:
5 District leaders and Everett and Walla Walla Vet Center Directors determine reasons for noncompliance with fire or safety annual inspection, ensure completion, and monitor compliance.
Closure Date:
6 District leaders and the Eugene and Everett Vet Center Directors determine reasons for noncompliance with monthly fire extinguisher inspections, ensure completion, and monitor compliance.
Closure Date:
7 District leaders and the Eugene and Everett Vet Center Directors determine reasons for noncompliance with annual fire extinguisher servicing, ensure completion, and monitor compliance.
Closure Date:
8 District leaders and the Eugene Vet Center Director determine reasons for noncompliance with having an automated external defibrillator located on-site and ensure compliance with the requirement.
Closure Date:
9 District leaders and the Everett and Walla Walla Vet Center Directors determine reasons for noncompliance with monthly automated external defibrillator inspections, ensure completion, and monitor compliance.
Closure Date:
10 District leaders and the Everett and Walla Walla Vet Center Directors determine reasons for noncompliance with building evacuation plans posted in a communal area for staff and visitors and ensure compliance with the requirement.
Closure Date:
11 District leaders and the Eugene and Walla Walla Vet Center Directors determine reasons for noncompliance with having an emergency and crisis plan that includes required components, ensure completion, and monitor compliance.
Closure Date:
12 District leaders and the Eugene, Everett, and Walla Walla Vet Center Directors determine reasons for noncompliance with a desktop reference sheet outlining steps for ancillary office staff to follow in case of a suicidal or homicidal client, ensure completion, and monitor compliance.
Closure Date:
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| 24-00388-266 | Inspection of Select Vet Centers in Pacific District 5 Zone 2 | Vet Center Inspection Program | ||
1 District leaders and the Kauai Vet Center Director determine reasons for noncompliance with assigning a licensed mental health professional as a clinical liaison, ensure a process is implemented, and monitor compliance.
Closure Date:
2 District leaders and the Corona, Temecula, Kauai, and Western Oahu Vet Center Directors determine reasons for noncompliance with completing four hours of external clinical consultation for clinically complex cases per month, ensure a process is implemented, and monitor compliance.
3 District leaders and the Western Oahu Vet Center Director determine reasons for noncompliance with Vet Center Director review of 10 percent of active client records monthly for each counselor’s caseload, ensure completion, and monitor compliance.
Closure Date:
4 District leaders and the Corona, Temecula, Kauai, and Western Oahu Vet Center Directors determine reasons for noncompliance with employees completing select trainings in the required time frame, ensure completion, and monitor compliance.
Closure Date:
5 District leaders and the Western Oahu Vet Center Director determine reasons for noncompliance with completion of a current written outreach plan, ensure completion, and monitor compliance.
Closure Date:
6 The District Director and zone leaders, in conjunction with the Corona, Temecula, and Kauai Vet Center Directors determine reasons for noncompliance with completion of an outreach plan with all required strategic components, ensure completion, and monitor compliance.
Closure Date:
7 District leaders and Western Oahu Vet Center Director determine reasons for noncompliance with fire or safety annual inspection, ensure completion, and monitor compliance.
Closure Date:
8 District leaders and the Corona, Temecula, and Western Oahu Vet Center Directors determine reasons for noncompliance with having an annual risk and vulnerability assessment completed by VA police or local law enforcement, ensure completion, and monitor compliance.
Closure Date:
9 District leaders and the Temecula and Western Oahu Vet Center Directors determine reasons for noncompliance with monthly fire extinguisher inspections, ensure completion, and monitor compliance.
Closure Date:
10 District leaders and the Temecula Vet Center Director determine reasons for noncompliance with annual fire extinguisher servicing, ensure completion, and monitor compliance.
Closure Date:
11 District leaders and the Corona, Temecula, and Kauai Vet Center Directors determine reasons for noncompliance with having an automated external defibrillator located on-site and ensure compliance with the requirement.
12 District leaders and the Western Oahu Vet Center Director determine reasons for noncompliance with monthly automated external defibrillator inspections, ensure completion, and monitor compliance.
Closure Date:
13 District leaders and the Kauai and Western Oahu Vet Center Directors determine reasons for noncompliance with having an updated emergency and crisis plan that includes required components, ensure completion, and monitor compliance.
Closure Date:
14 District leaders and the Western Oahu Vet Center Director determine reasons for noncompliance with a desktop reference sheet outlining steps for ancillary office staff to follow in case of a suicidal or homicidal client, ensure completion, and monitor compliance.
Closure Date:
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| 24-00389-267 | Inspection of Select Vet Centers in Pacific District 5 Zone 3 | Vet Center Inspection Program | ||
1 District leaders and the Phoenix and West Valley Vet Center Director collaborate with the support VA medical facility to determine reasons for noncompliance with staff participation on the mental health executive council, take action as indicated, and monitor compliance.
Closure Date:
2 District leaders and the Antelope Valley, Phoenix, and West Valley Vet Center Directors determine reasons for noncompliance with completing four hours of external clinical consultation for clinically complex cases per month, ensure a process is implemented, and monitor compliance.
Closure Date:
3 District leaders and the West Valley Vet Center Director determine reasons for noncompliance with Vet Center Director review of 10 percent of active client records monthly for each counselor’s caseload, ensure completion, and monitor compliance.
Closure Date:
4 District leaders and the Antelope Valley Vet Center Director determine reasons for noncompliance with employees completing select trainings in the required time frame, ensure completion, and monitor compliance.
Closure Date:
5 District leaders and the Antelope Valley, Phoenix, Santa Fe, and West Valley Vet Center Directors determine reasons for noncompliance with completion of an outreach plan with all required strategic components, ensure completion, and monitor compliance.
Closure Date:
6 District leaders and the Santa Fe Vet Center Director determine reasons for noncompliance with having an annual risk and vulnerability assessment completed by VA police or local law enforcement, ensure completion, and monitor compliance.
Closure Date:
7 District leaders and the Antelope Valley Vet Center Director determine reasons for noncompliance with monthly fire extinguisher inspections, ensure completion, and monitor compliance.
Closure Date:
8 District leaders and the Antelope Valley and Santa Fe Vet Center Directors determine reasons for noncompliance with having an automated external defibrillator located on-site and ensure compliance with the requirement.
Closure Date:
9 District leaders and the Phoenix and Santa Fe Vet Center Directors determine reasons for noncompliance with having an emergency and crisis plan that includes required components, ensure completion, and monitor compliance.
Closure Date:
10 District leaders and the Santa Fe Vet Center Director determine reasons for noncompliance with a desktop reference sheet outlining steps for ancillary office staff to follow in case of a suicidal or homicidal client, ensure completion, and monitor compliance.
Closure Date:
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| 23-03679-262 | Leaders Failed to Address Community Care Consult Delays Despite Staff’s Advocacy Efforts at VA Western New York Healthcare System in Buffalo | Hotline Healthcare Inspection | ||
1 The New York/New Jersey VA Health Care Network Director conducts a review of system leaders’ responses to repeated concerns regarding delayed community care consult scheduling for patients with serious health conditions to determine whether leaders’ actions were in alignment with patient safety and high reliability organizational principles, and take action as warranted.
Closure Date:
2 The New York/New Jersey VA Health Care Network Director ensures VA Western New York Health Care System Director develops community care consult practices and procedures for managing consults deemed high-risk or complex, implements an effective process to ensure consistency with processing consults within Veterans Health Administration timeliness requirements, and audits for compliance.
Closure Date:
3 The VA Western New York Health Care System Director ensures system community care leaders develop and implement standardized operating procedures for consult management consistent with Veterans Health Administration standards, provide training to community care staff, monitor compliance, and evaluate effectiveness.
Closure Date:
4 The VA Western New York Health Care System Director ensures all efforts to conduct an institutional disclosure to Patient A’s family are made and that the disclosure is documented in the patient’s electronic health record, as required.
Closure Date:
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| 23-02393-250 | Mismanaged Mental Health Care for a Patient Who Died by Suicide and Review of Administrative Actions at the VA Tuscaloosa Healthcare System in Alabama | Hotline Healthcare Inspection | ||
1 The VA Tuscaloosa Healthcare System Director conducts a full review of care provided to the patient by clinical staff, consults with Human Resources and General Counsel Offices, and takes action as needed.
Closure Date:
2 The VA Tuscaloosa Healthcare System Director strengthens processes to ensure that providers provide patient education about applicable boxed warnings when prescribing psychiatric medication, and monitors compliance.
3 The VA Tuscaloosa Healthcare System Director ensures mental health staff conduct suicide risk screenings and assessments as required by the Veterans Health Administration, and monitors compliance.
4 The VA Tuscaloosa Healthcare System Director evaluates outpatient mental health clinic scheduling procedures; identifies barriers to timely appointment scheduling, including staffing levels; and takes action as warranted.
Closure Date:
5 The VA Tuscaloosa Healthcare System Director strengthens processes to ensure adequate lethal means assessment and lethal means safety counseling with patients.
Closure Date:
6 The VA Tuscaloosa Healthcare System Director reviews posttraumatic stress disorder clinic processes to consult with a patient’s prescriber following worsening of a patient’s mental health symptoms.
Closure Date:
7 The VA Tuscaloosa Healthcare System Director ensures posttraumatic stress disorder clinic consult and documentation procedures align with Veterans Health Administration requirements.
Closure Date:
8 The VA Tuscaloosa Healthcare System Director conducts a review of the supervisory oversight of the social worker and other clinicians in the posttraumatic stress disorder clinic to ensure the identification and follow-up of clinical concerns for patients with complex mental health needs.
9 The VA Tuscaloosa Healthcare System Director strengthens processes to ensure adherence to Veterans Health Administration and facility traumatic brain injury screening and consult requirements, and monitors compliance.
Closure Date:
10 The VA Tuscaloosa Healthcare System Director evaluates the root cause analysis processes regarding reporting of incomplete action items in accordance with Veterans Health Administration requirements, takes action as needed, and monitors compliance.
Closure Date:
11 The VA Tuscaloosa Healthcare System Director evaluates the Peer Review Committee processes on addressing identified system issues in accordance with Veterans Health Administration requirements, takes action as needed, and monitors compliance.
Closure Date:
12 The Under Secretary for Health considers establishing written guidance regarding the Behavioral Health Autopsy Program family interview process, including suicide prevention program staff’s consultation, to ensure that the decision to not outreach a family member is based on the best interest of the family.
Closure Date:
13 The VA Tuscaloosa Healthcare System Director ensures compliance with the Behavioral Health Autopsy Program including completion of the Family Interview Tool-Contact Form.
Closure Date:
14 The VA Tuscaloosa Healthcare System Director evaluates the care provided to the patient, determines if an institutional disclosure is warranted, and takes action as indicated.
Closure Date:
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| 24-00675-259 | Mental Health Inspection of the VA Augusta Health Care System in Georgia | Mental Health Inspection Program | ||
1 The VA Augusta Health Care System Director ensures that the Mental Health Executive Council includes veteran representation.
Closure Date:
2 The Veterans Integrated Service Network Director implements processes to strengthen oversight and monitoring of bed utilization.
Closure Date:
3 The VA Augusta Health Care System Associate Director for Patient Care Services ensures that inpatient mental health unit staffing supports authorized bed capacity.
Closure Date:
4 The VA Augusta Health Care System Director develops and implements processes to incorporate veteran input for process improvements.
5 The VA Augusta Health Care System Chief of Mental Health develops processes to ensure integration of the Local Recovery Coordinator into the inpatient mental health unit to support recovery-oriented care.
Closure Date:
6 The VA Augusta Health Care System Chief of Mental Health ensures a minimum of four hours of recovery-oriented, interdisciplinary programming on weekends on the inpatient mental health unit.
7 The VA Augusta Health Care System Director ensures continued implementation of a recovery-oriented environment on the inpatient mental health unit.
Closure Date:
8 The VA Augusta Health Care System Director ensures accurate reporting of inpatient operating beds and implements processes to monitor.
Closure Date:
9 The VA Augusta Health Care System Director identifies and addresses barriers to admission for veterans on involuntary holds for mental health treatment.
Closure Date:
10 The VA Augusta Health Care System Director ensures alignment between involuntary commitment policies and practices, consistency with state laws, and implementation of monitoring processes.
11 The VA Augusta Health Care System Chief of Staff ensures assignment of ongoing responsibilities for monitoring timely documentation of the change in veterans’ voluntary or involuntary legal status, consistent with VHA policy and state laws.
Closure Date:
12 The VA Augusta Health Care System Chief of Staff ensures timely documentation of discussions between the prescriber and veteran on the risks and benefits of newly prescribed medications and monitors for improvement.
Closure Date:
13 The VA Augusta Health Care System Director ensures the development and implementation of clearly defined written processes for transition of care when veterans are discharged from the inpatient mental health unit.
Closure Date:
14 The VA Augusta Health Care System Chief of Staff ensures discharge summaries are completed within two business days of discharge and monitors for compliance.
Closure Date:
15 The VA Augusta Health Care System Chief of Staff ensures discharge instructions for veterans include appointment location and contact information in easy-to-understand language.
Closure Date:
16 The VA Augusta Health Care System Director ensures that medications listed in discharge instructions include the purpose for each medication and are written in easy-to-understand language.
17 The VA Augusta Health Care System Chief of Staff identifies barriers to completing the Columbia-Suicide Severity Risk Scale Screener within 24 hours prior to discharge, implements processes, and monitors to ensure compliance.
Closure Date:
18 The VA Augusta Health Care System Chief of Staff ensures that safety plans address ways to make the veteran’s environment safer from potentially lethal means and monitors for compliance.
Closure Date:
19 The VA Augusta Health Care System Director ensures staff comply with lethal means safety training and suicide risk training requirements and monitors for compliance.
20 The VA Augusta Health Care System Director ensures compliance with VHA requirements for the Interdisciplinary Safety Inspection Team, including environment of care subcommittee structure, and Mental Health Environment of Care Checklist training completion.
Closure Date:
21 The VA Augusta Health Care System Chief of Staff ensures mental health leaders update inpatient unit toilets to meet safety requirements and implement processes to reduce associated safety risks.
Closure Date:
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14921