Recommendations
2056
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 22-00900-186 | Review of Perceived Barriers in Coordinating Veteran Maternity Care | National Healthcare Review | ||
1 The Under Secretary for Health requires facilities to review designated time for Maternity Care Coordinator caseload, and assigned collateral duties, to determine if additional staffing resources are needed to support Veterans Health Administration Maternity Care Coordination, and takes action as appropriate.
2 The Under Secretary for Health reviews timeliness of facility community care maternity care referrals to ensure timely access for routine and expedited (high-risk and late term) referrals, and takes action as appropriate.
Closure Date:
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| 23-01266-78 | VBA Did Not Identify All Vietnam Veterans Who Could Qualify for Retroactive Benefits | Review | ||
1 Ensure Veterans Benefits Administration staff use improved methodologies similar to the Office of Inspector General’s review to identify eligible veterans, readjudicate claims, and send outreach letters to potential Nehmer class members who could qualify for retroactive benefits under the National Defense Authorization Act.
2 Ensure claims processors at screening sites understand the need to identify any claims that may warrant readjudication by meeting the Nehmer consent decree and subsequent court orders.
Closure Date:
3 Update the standard operating procedures to have staff consider whether veterans’ medical records show a diagnosis of the now-covered herbicide-related diseases at the time of any prior disability benefits claim before January 1, 2021, regardless of whether a current claim is for a disease recognized by the National Defense Authorization Act.
Closure Date:
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| 23-02179-188 | Leaders at the VA Eastern Colorado Health Care System in Aurora Created an Environment That Undermined the Culture of Safety | Hotline Healthcare Inspection | ||
1 The Under Secretary for Health conducts a review of the Veterans Integrated Service Network leaders’ awareness and oversight of the VA Eastern Colorado Health Care System’s operations including clinical staffing, hiring and retention of qualified candidates, and leaders’ adherence to high reliability organizational principles.
Closure Date:
2 The Under Secretary for Health utilizes the above review to standardize Veterans Integrated Service Network leaders’ roles and responsibilities across the system to ensure each Veterans Integrated Service Network practices structured and robust oversight activities in support of high-quality healthcare delivery at each healthcare facility.
3 The Veterans Integrated Service Network Director conducts a review to determine whether the actions of the Facility Director, Chief of Staff, deputy chief of staff for inpatient operations, and the associate chief of staff for education created and reinforced a culture of fear and failed to adhere to high reliability organizational principles, and takes action as needed.
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4 The Veterans Integrated Service Network Director develops and implements an avenue for VA Eastern Colorado Health Care System’s employees to provide periodic feedback regarding the culture of safety and leaders’ practice of and adherence to high reliability principles.
Closure Date:
5 The Veterans Integrated Service Network Director ensures the VA Eastern Colorado Health Care System Director evaluates clinical service leader vacancies throughout the facility and takes actions to prioritize the recruitment and hiring of qualified clinical leaders.
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6 The Veterans Integrated Service Network Director ensures human resources officers provide separating and transferring employees access to the most current version of the VA exit and transfer surveys.
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7 The VA Eastern Colorado Health Care System Director and leaders actively seek and utilize employee exit survey data to identify challenges with employee retention, develop and implement actions to address challenges, and evaluate the effectiveness of actions.
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| 23-02179-189 | Extended Pause in Cardiac Surgeries and Leaders’ Inadequate Planning of Intensive Care Unit Change and Negative Impact on Resident Education at the VA Eastern Colorado Health Care System in Aurora | Hotline Healthcare Inspection | ||
1 The Under Secretary for Health evaluates the circumstances that led to Veterans Integrated Service Network leaders’ lack of awareness of the 11-month curtailment of cardiothoracic surgeries and takes action as needed to ensure effective Veterans Integrated Service Network oversight of facility clinical operations.
Closure Date:
2 The Veterans Integrated Service Network Director evaluates the circumstances that led to the failure of VA Eastern Colorado Health Care System leaders to submit a proposal request and business plan to resume cardiothoracic surgeries after an 11-month pause to the Veterans Integrated Service Network Director for review and approval and takes action as needed.
Closure Date:
3 The Veterans Integrated Service Network Director ensures facility leaders implement high reliability organization principles to plan for clinical operation changes that include stakeholders, service and section leaders, and staff input.
Closure Date:
4 The Veterans Integrated Service Network Director ensures that the educational needs of the facility’s residents are evaluated and maintained during service and program changes, including on-site supervision, as required by Veterans Health Administration directive.
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5 The VA Eastern Colorado Health Care System Director reviews and finalizes Facility Draft Policy 11-55 titled Call Escalation of Communication and trains attendings, fellows, residents, and staff members on the policy.
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6 The VA Eastern Colorado Health Care System Director reviews root cause analysis requirements for interviewing individuals relevant to root cause analyses and ensures staff are trained accordingly.
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| 23-00460-185 | Deficiencies in Oversight and Leadership Response to Optometry Concerns at the Cheyenne VA Medical Center in Wyoming | Hotline Healthcare Inspection | ||
1 The Veterans Integrated Service Network Director, in conjunction with facility leaders and optometry service leaders, conducts a comprehensive review of the quality of care provided by the optometrist, identifies deficiencies, and takes action as indicated.
Closure Date:
2 The Cheyenne VA Medical Center Director ensures compliance with Veterans Health Administration requirements for state licensing board reporting of the care provided by the optometrist and takes action, including training, as indicated.
Closure Date:
3 The Cheyenne VA Medical Center Director reviews optometry service proficiency processes, identifies deficiencies, and takes action as indicated.
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| 23-01397-126 | Ineffective Use and Oversight of Medical/Surgical Prime Vendor Program Led to Increased Spending | Audit | ||
1 Ensure facility staff place all orders for eligible items through the Medical/Surgical Prime Vendor program, including those that are identified as on back order.
Closure Date:
2 Implement tracking mechanisms for back orders to assist the facilities in not obtaining excess supplies.
3 Ensure that logistics staff receive training and use the Prime Vendor Conversion and Recommendation Tool to identify commonly purchased open market items and convert those items to Medical/Surgical Prime Vendor purchases.
Closure Date:
4 Identify and implement an efficient way to transfer product list updates to the inventory ordering system.
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5 In collaboration with the Strategic Acquisition Center, identify a VA-owned system for staff to check product information, such as availability and pricing, and ensure applicable facility staff are aware of this location.
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6 Implement a standardized, routine review of open market purchases.
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7 Ensure that reporting tools are effective and consistently applied, and that reported issues are resolved.
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8 Ensure that logistics staff receive relevant Medical/Surgical Prime Vendor program guidance and training.
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9 Ensure the product list includes items that facilities need and regularly purchase so the Veterans Health Administration can expand the savings and benefits the Medical/Surgical Prime Vendor program offers.
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| 23-02181-98 | Financial Efficiency Inspection of the VA North Texas Health Care System | Financial Inspection | ||
1 Establish a plan to use VA’s cost accounting system information to identify alternative ways to reduce costs, enhance efficiency, and inform business decisions as identified by VA financial policy.
Closure Date:
2 Ensure healthcare system staff responsible for labor cost and workload mapping are responding in a timely manner to the results of managerial cost accounting audits and correcting all identified issues.
Closure Date:
3 Consider a plan to align VA North Texas Health Care System financial management practices with federal financial accounting standard practices. This could include using cost information for performance measurement, budgeting, and cost control, and making economic choices.
Closure Date:
4 Ensure that healthcare system staff are made aware of policy requirements and the responsible finance office conducts monthly reviews and reconciliations on all open obligations for financial validity and take appropriate actions as required by VA Financial Policy, vol. 2, chap. 5, “Obligations” (2020), updated May 2023.
Closure Date:
5 Consult with Office of General Counsel and Office of Acquisitions, Logistics and Construction to determine if any further actions are necessary, including contract modifications, to remedy and prevent future purpose statute and bona fide needs rule violations.
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6 Establish controls to ensure cardholders comply with record retention requirements, confirm approving officials and cardholders review purchases for VA policy compliance, and ensure contracting is used when it is in the best interest of the government.
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7 Require cardholders to submit a request for ratification for any unauthorized commitments identified.
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8 Develop and implement a plan to ensure data accuracy and reliability in the Generic Inventory Package in accordance with Veterans Health Administration policy.
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9 Continue to develop and implement processes to ensure all necessary reports are monitored routinely and appropriate steps are taken to ensure all supply chain performance measures are maintained in compliance with policy.
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| 23-02330-127 | Inspection of Information Security at the VA Bedford Healthcare System in Massachusetts | Information Security Inspection | ||
1 Obtain an inventory of locally managed databases, perform configuration compliance scans, provide the facility with a copy of the scan results, and monitor the facility’s remediation efforts.
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2 Implement a process to verify system owners review user account access to locally managed databases.
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3 Implement effective system life-cycle processes to ensure network devices meet standards mandated by the VA Office of Information and Technology Configuration Control Board.
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4 Develop and approve an authorization to operate for the special-purpose systems.
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5 Include system personnel during the security categorization process to ensure that all necessary information types are considered when determining the security categorization for special-purpose systems.
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6 Implement controls to ensure the accuracy of user locations supporting the Lynx Duress system.
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7 Implement the appropriate physical security controls to restrict and monitor access to the facility, its server room, and communication closets.
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8 Implement and monitor emergency power and uninterruptible power supplies in all communication closets.
Closure Date:
9 Implement grounding equipment in all communication closets.
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| 23-02186-97 | Follow-Up Information Security Inspection at the VA Financial Services Center in Austin, Texas | Information Security Inspection | ||
1 Implement a more effective vulnerability management program to address security deficiencies identified during the inspection. (This is a repeat recommendation from the prior inspection.)
Closure Date:
2 Ensure vulnerabilities are remediated within OIT’s established time frames. (This is a repeat recommendation from the prior inspection.)
3 Ensure all servers and databases are part of the automated scanning process.
Closure Date:
4 Implement approved baseline configurations for databases and document justifications and approvals for any deviations.
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5 Implement more effective configuration control processes to ensure network devices maintain vendor support and receive security updates.
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6 Implement an improved inventory process to ensure the accuracy of network ranges managed within the Enterprise Mission Assurance Support Service. (This is a repeat recommendation from the prior inspection.)
Closure Date:
7 Implement an effective audit and monitoring process for all servers and databases. (This is a repeat recommendation from the prior inspection.)
Closure Date:
8 Ensure that physical access logs for the data center and communication rooms are reviewed on a quarterly basis.
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| 23-03063-164 | Evaluation of the May 2023 Power Outage at the Hines Information Technology Center in Illinois | Review | ||
1 Consider taking appropriate steps to implement redundant distribution paths between the uninterruptible power supplies and the information technology equipment at the Hines Information Technology Center.
Closure Date:
2 Implement steps to prevent the inadvertent activation of the main circuit breaker at the Hines Information Technology Center, such as installing a protective covering over the circuit breaker with an explicit warning label indicating the breaker’s function to help prevent power outages at the facility.
Closure Date:
3 Implement steps to prevent the inadvertent activation of circuit breakers at all VA data centers, such as updating the physical security controls policy to require protective covers and explicit warning labels.
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4 Update the Hines Information Technology Center information system contingency plan to help ensure the efficient restoration of data center power and critical applications in the event of a power outage.
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5 Implement annual testing of Hines Information Technology Center contingency and restoration procedures following a power loss to ensure all stakeholders are aware of their responsibilities in accordance with revised information system contingency plan procedures.
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14921