Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 13-04324-170 | Inspection of the VA Regional Office, Reno, Nevada | Review | ||
1 We recommend the Reno VA Regional Office Director implement a plan to ensure timely and appropriate action on reminder notifications for medical reexaminations.
Closure Date:
2 We recommend the Reno VA Regional Office Director conduct a review of the 275 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate action.
Closure Date:
3 We recommend the Reno VA Regional Office Director ensure required staff receive refresher training on how to identify insufficient traumatic brain injury medical examination reports and return them to the appropriate VA medical facilities for correction.
Closure Date:
4 We recommend the Reno VA Regional Office Director conduct training on the proper processing of special monthly compensation and ancillary benefits claims and implement a plan to assess the effectiveness of that training.
Closure Date:
5 We recommend the Reno VA Regional Office Director develop and implement a plan to ensure adequate and continuous oversight is provided for the timely completion of the annual Systematic Analyses of Operations schedule and the required 11 Systematic Analyses of Operations.
Closure Date:
6 We recommend the Reno VA Regional Office Director ensure that staff assigned to complete Systematic Analyses of Operations receive training on Veterans Benefits Administration policy regarding the purpose and requirements for completing Systematic Analyses of Operations.
Closure Date:
7 We recommend the Reno VA Regional Office Director amend the workload management plan to ensure oversight and prioritization of benefit reduction cases.
Closure Date:
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| 13-04592-179 | Healthcare Inspection – Alleged Preventive Maintenance Inspection Deficiencies, Northern Arizona VA Health Care System, Prescott, Arizona | Hotline Healthcare Inspection | ||
1 We recommended that the System Director initiate actions to address medical equipment with expired preventive maintenance inspections, that processes be strengthened to identify and track deficiencies to closure, and that compliance is monitored.
Closure Date:
2 We recommended that the System Director assess staffing in the Biomedical Engineering Department and take appropriate actions to meet the workload requirements.
Closure Date:
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| 13-04195-180 | Healthcare Inspection – Quality of Care Concerns, Hospice/Palliative Care Program, VA Western New York Healthcare System, Buffalo, New York | Hotline Healthcare Inspection | ||
1 13-04195-180
Closure Date:
2 13-04195-180
Closure Date:
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| 14-01686-185 | Follow-up Audit of VBA's 100 Percent Disability Evaluations | Audit | ||
1 We recommend the Under Secretary for Benefits ensure regional office staff take the appropriate action to review and process the records of all veterans with a temporary 100 percent disability evaluation within 180 days of the veteran’s inclusion on the TRAP report or the veteran’s scheduled exam.
2 We recommend the Under Secretary for Benefits ensure regional offices transfer from the Records Management Center all claims folders with temporary 100 percent disability evaluations to the regional office of jurisdiction.
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| 13-02129-177 | Audit of VBA’s Management of Concurrent VA and Military Drill Pay Compensation | Audit | ||
1 We recommended the Under Secretary for Benefits take measures to ensure drill pay offsets identified after fiscal year 2012 are timely processed.
Closure Date:
2 We recommended the Under Secretary for Benefits ensure fiscal years 2011 and 2012 drill pay offsets are processed.
Closure Date:
3 We recommended the Under Secretary for Benefits modify existing information technology systems to more effectively monitor, track, and report on drill pay offset activities.
Closure Date:
4 We recommended the Under Secretary for Benefits update the cost-benefit analysis regularly and use it to prioritize the processing of drill pay offsets.
Closure Date:
5 We recommended the Under Secretary for Benefits require Systematic Analysis of Operations be completed annually for drill pay matching activities.
Closure Date:
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| 13-01391-72 | VA's Federal Information Security Management Act Audit for Fiscal Year 2013 | Audit | ||
1 We recommend the Executive in Charge for Information and Technology fully develop and implement an agency-wide risk management governance structure, along with mechanisms to identify, monitor, and manage risks across the enterprise. (This is a repeat recommendation from last year.)
2 We recommend the Executive in Charge for Information and Technology implement mechanisms to ensure sufficient supporting documentation is captured in the central database to justify closure of Plans of Action and Milestones. (This is a repeat recommendation from last year.)
3 We recommend the Executive in Charge for Information and Technology define and implement clear roles and responsibilities for developing, maintaining, completing, and reporting Plans of Action and Milestones. (This is a repeat recommendation from last year.)
4 We recommend the Executive in Charge for Information and Technology implement mechanisms to ensure Plans of Action and Milestones are updated to accurately reflect current status information. (This is a repeat recommendation from last year.)
5 We recommend the Executive in Charge for Information and Technology develop mechanisms to ensure system security plans reflect current operational environments, including accurate system interconnection and ownership information. (This is a repeat recommendation from last year.)
6 We recommend the Executive in Charge for Information and Technology implement improved processes for updating key security documents such as risk assessments, security impact analyses, and security self-assessments on at least an annual basis and ensure all required information accurately reflects the current environment and new risks in accordance with Federal standards. (This is a new recommendation.)
7 We recommend 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 last year.)
8 We recommend the Executive in Charge for Information and Technology implement periodic access 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 last year.)
9 We recommend the Executive in Charge for Information and Technology enable system audit logs and conduct centralized reviews of security violations on mission-critical systems. (This is a repeat recommendation from last year.)
10 We recommend the Executive in Charge for Information and Technology implement mechanisms to ensure all remote access computers have updated security patches and antivirus definitions prior to connecting to VA information systems. (This is a repeat recommendation from last year.)
11 We recommend the Executive in Charge for Information and Technology implement two-factor authentication for remote access throughout the agency. (This is a repeat recommendation from last year.)
12 We recommend the Executive in Charge for Information and Technology develop and implement policies and procedures for restricting privileged remote access from foreign countries that may pose a significant security risk to VA systems. (This is a new recommendation.)
13 We recommend the Executive in Charge for Information and Technology implement 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 last year.)
14 We recommend the Executive in Charge for Information and Technology implement a patch and vulnerability management program to address security deficiencies identified during our assessments of VA’s Web applications, database platforms, network infrastructure, and work stations. (This is a modified repeat recommendation from last year.)
15 We recommend the Executive in Charge for Information and Technology implement standard security configuration baselines for all VA operating systems, databases, applications, and network devices. (This is a repeat recommendation from last year.)
16 We recommend the Executive in Charge for Information and Technology implement procedures to enforce a system development and change control framework that integrates information security throughout the life cycle of each system. (This is a repeat recommendation from last year.)
17 We recommend the Executive in Charge for Information and Technology implement processes to ensure information system contingency plans are updated with the required information and lessons learned are communicated to senior management. (This is a repeat recommendation from last year.)
18 We recommend the Executive in Charge for Information and Technology develop and implement a process for ensuring the encryption of backup data prior to transferring the data offsite. (This is a new recommendation.)
19 We recommend the Executive in Charge for Information and Technology ensure that agreements for alternate processing sites have been established that define the roles and responsibilities for alternate locations in the event of a disaster. (This is a new recommendation.)
20 We recommend the Executive in Charge for Information and Technology review change management procedures to ensure that any changes to system procedures are appropriately tested, validated, documented and approved. (This is a repeat recommendation from last year.)
21 We recommend the Executive in Charge for Information and Technology fully implement an automated 24-hour security event and incident correlation solution to monitor security for all systems interconnections, database security events, and mission-critical platforms supporting VA programs and operations. (This is a repeat recommendation from last year.)
22 We recommend the Executive in Charge for Information and Technology identify all external network interconnections and ensure appropriate Interconnection Security Agreements and Memoranda of Understanding are in place to govern them. (This is a repeat recommendation from last year.)
23 We recommend the Executive in Charge for Information and Technology implement more effective agency-wide incident response procedures to ensure timely resolution of computer security incidents in accordance with VA set standards. (This is a repeat recommendation from last year.)
24 We recommend the Executive in Charge for Information and Technology provide the OIG with timely and formal notifications of network intrusions and system compromises in accordance with FISMA. (This is a new recommendation.)
25 We recommend the Executive in Charge for Information and Technology develop a listing of approved software and implement continuous monitoring processes to identify and prevent the use of unauthorized application software, hardware and system configurations on its networks. (This is a modified repeat recommendation from last year.)
26 We recommend the Executive in Charge for Information and Technology develop a comprehensive software inventory process to identify major and minor software applications used to support VA programs and operations. (This is a modified repeat recommendation from last year.)
27 We recommend the Acting Assistant Secretary for Information and Technology develop procedures to integrate information security costs into the capital planning process while ensuring traceability of Plans of Action and Milestones remediation costs to appropriate capital planning budget documents. (This is a repeat recommendation from last year.)
28 We recommend the Executive in Charge for Information and Technology implement procedures for overseeing contractor-managed cloud-based systems, ensuring OIG access to those systems, and ensuring information security controls adequately protect VA sensitive systems and data. (This is a modified repeat recommendation from last year.)
29 We recommend the Executive in Charge for Information and Technology implement mechanisms for updating the Federal Information Security Management Act systems inventory, including contractor-managed systems and interfaces, and annually review the systems inventory for accuracy. (This is a repeat recommendation from last year.)
30 We recommend the Executive in Charge for Information and Technology implement mechanisms to ensure all users with VA network access participate in and complete required VA-sponsored security awareness training. (This is a repeat recommendation from last year.)
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| 14-01119-168 | Healthcare Inspection – Community Living Center Patient Care, Gulf Coast Veterans Health Care System, Biloxi, Mississippi | Hotline Healthcare Inspection | ||
1 We recommended that the System Director actively recruits and fills approved physician vacancies within the Extended Care Service.
Closure Date:
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| 13-03018-159 | Review of Alleged Mismanagement of VBA's Eastern Area Fiduciary Hub | Audit | ||
1 We recommended the Under Secretary for Benefits require the Eastern Area Fiduciary Hub to implement controls to monitor misuse determinations to ensure reviews meet timeliness standards.
Closure Date:
2 We recommended the Under Secretary for Benefits require the Director of Pension and Fiduciary Service to implement controls to monitor negligence reviews.
Closure Date:
3 We recommended the Under Secretary for Benefits implement controls to ensure the reissuance of misused funds to beneficiaries and repayment from former fiduciaries occurs timely.
Closure Date:
4 We recommended the Under Secretary for Benefits require the Director of Pension and Fiduciary Services to conduct a negligence review of the 12 identified cases of misuse of beneficiary funds and determine if misused funds are required to be reissued to affected beneficiaries.
Closure Date:
5 We recommended the Under Secretary for Benefits ensures the Eastern Area Fiduciary Hub implements a plan to expedite completion of their backlog of field examinations to meet performance standards.
Closure Date:
6 We recommended the Under Secretary for Benefits require the Director of the Indianapolis VA Regional Office to implement a plan to ensure the Eastern Area Fiduciary Hub eliminates its backlog of Fiduciary Program mail during FY 2014.
Closure Date:
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| 14-02603-178 | Interim Report: Review of VHA's Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths at the Phoenix Health Care System | Audit | ||
1 We recommend the VA Secretary take immediate action to review and provide appropriate health care to the 1,700 veterans we identified as not being on any existing wait list.
Closure Date:
2 We recommend the VA Secretary review all existing wait lists at the Phoenix Health Care System to identify veterans who may be at greatest risk because of a delay in the delivery of health care (for example, those veterans who would be new patients to a specialty clinic) and provide the appropriate medical care.
Closure Date:
3 We recommend the VA Secretary initiate a nationwide review of veterans on wait lists to ensure that veterans are seen in an appropriate time, given their clinical condition.
Closure Date:
4 We recommend the VA Secretary direct the Health Eligibility Center to run a nationwide New Enrollee Appointment Request report by facility of all newly enrolled veterans and direct facility leadership to ensure all veterans have received appropriate care or are shown on the facility's electronic waiting list.
Closure Date:
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| 14-00686-166 | Combined Assessment Program Review of the Aleda E. Lutz VA Medical Center, Saginaw, Michigan | Comprehensive Healthcare Inspection Program | ||
1 We recommended that nursing managers fully implement the plan approved in March 2014.
Closure Date:
2 We recommended that the annual staffing plan reassessment process ensures that the facility expert panel includes all required members.
Closure Date:
3 We recommended that the annual staffing plan reassessment process ensures that the acute care unit-based expert panel includes all required members.
Closure Date:
4 We recommended that processes be strengthened to ensure that acute care staff accurately document the risk scale score for all patients with pressure ulcers and that compliance be monitored.
Closure Date:
5 We recommended that the facility establish staff pressure ulcer education requirements and that compliance be monitored.
Closure Date:
6 We recommended that processes be strengthened to ensure that wound care specialist consults are initiated and completed for all patients with pressure ulcers and that compliance be monitored.
Closure Date:
7 We recommended that processes be strengthened to ensure that staff complete and document restorative nursing services according to residents' care plans and that compliance be monitored.
Closure Date:
8 We recommended that processes be strengthened to ensure that staff document residents' progress toward restorative nursing goals and that compliance be monitored.
Closure Date:
9 We recommended that processes be strengthened to ensure that staff document residents' restorative progress bi-weekly and that compliance be monitored.
Closure Date:
10 We recommended that processes be strengthened to ensure that all required participants or their designees attend weekly EOC rounds and that compliance be monitored.
Closure Date:
11 We recommended that processes be strengthened to ensure that all required participants or their designees attend weekly EOC rounds and that compliance be monitored.
Closure Date:
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15039