Recommendations
2183
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 25-03621-145 | Review of Medical Facilities’ Management of Specialty Care Calls | Review | ||
1 Create a process for facilities to regularly update and verify specialty care clinics’ phone numbers listed in internal facility directories and on websites.
2 Annually evaluate and verify that automated interactive phone systems route veterans directly to the correct specialty care clinic and assess whether the phone systems support first-call resolution.
3 Reconfigure specialty care clinics’ phone lines to be able to collect required call performance data and assess whether centralized queues enhance the efficiency of phone management.
4 Provide guidance to specialty care clinics on how they should manage and respond to voicemails, including for routine reviews of voicemail data.
5 Provide guidance that assigns both the responsibility for and the frequency of routine monitoring of call performance data and analyses of complaint data trends from the patient advocate system to identify and address veterans’ phone access issues for specialty care clinics.
| ||||
| 25-02887-107 | Review of Open Obligations in VBA’s General Operating Expenses Account | Review | ||
1 Standardize and enforce a documented monthly process for reviewing and validating open obligations—including undelivered orders and accruals—with defined staff roles, responsibilities, and communication protocols, in alignment with VA financial policy.
2 In conjunction with the Office of Acquisition, Logistics, and Construction, establish and document procedures that define roles and communication requirements with requesting and contracting offices to ensure timely end-date modifications and deobligation of funds that are no longer needed.
3 In coordination with the VA Office of Financial Policy, develop VBA‑specific procedures aligned with appendix F of VA Financial Policy, “Obligations,” and confirm those procedures are consistently implemented to support reconciliation, documentation, and closure of open obligations in the Integrated Financial and Acquisition Management System.
Total Monetary Impact of All Recommendations
Open: $895,257,953
Closed: $0
Total: $895,257,953
| ||||
| 25-00253-156 | Healthcare Facility Inspection of the VA San Diego Healthcare System in California | Healthcare Facility Inspection | ||
1 Facility leaders ensure staff follow procedures to properly separate and store soiled and clean equipment.
Closure Date:
2 Facility leaders ensure environmental management services staff clean ice machines daily to help prevent infection risk.
Closure Date:
3 Facility leaders ensure staff properly label and store oxygen tanks.
Closure Date:
4 Facility leaders ensure staff update the facility policy to include all elements to communicate test results to patients, as required in Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.
| ||||
| 25-00193-155 | Healthcare Facility Inspection of the VA El Paso Healthcare System in Texas | Healthcare Facility Inspection | ||
1 Executive leaders ensure staff maintain a clean and safe environment.
2 The Medical Center Director ensures providers complete secondary toxic exposure screenings within 30 days.
| ||||
| 25-01781-71 | Audit of Security and Access Controls for the Patient Advocate Tracking System-Replacement | Audit | ||
1 Ensure that authorizations are reassessed when a significant change affects the security or privacy posture of an application, consistent with the requirements of VA Handbook 6500.
Closure Date:
2 Reevaluate the risk determination for the Patient Advocate Tracking System‑Replacement and determine the appropriate security categorization level and system classification based on (1) the sensitive personal information maintained in the system and (2) the System Security Categorization Report.
3 Reevaluate whether there is a continued business need to maintain access to veterans’ medical records in the Patient Advocate Tracking System-Replacement.
4 Institute a process to ensure user roles are regularly reviewed for continued access and evaluate the effectiveness of the access control principle of least privilege to ensure roles for the Patient Advocate Tracking System-Replacement are correctly configured and allow access only for authorized users.
5 Update the Patient Advocate Tracking System-Replacement user guides and training materials.
| ||||
| 25-02402-83 | Follow-Up Inspection of Information Security at the VA Southern Oregon Healthcare System | Information Security Inspection | ||
1 Improve the existing vulnerability management process to make sure all vulnerabilities are identified, plans of action and milestones are created for vulnerabilities that cannot be mitigated by VA deadlines, and software is updated before vendor support ends.
2 Implement a baseline configuration process to make sure network devices and databases are running authorized software that is configured to approved baselines and free of vulnerabilities.
3 Implement a process to disable access to the active directory and the electronic health record when temporary staff leave before their expected end date.
Closure Date:
4 Separate the duties of maintaining physical blank key stock and making keys to improve physical access controls over key inventories.
Closure Date:
5 Secure network infrastructure in accordance with VA environmental protection standards.
6 Complete the installation of grounding measures for all telecommunication closets to protect information technology equipment.
7 Routinely monitor and service uninterruptible power supplies that support the network infrastructure.
8 Establish a process to make sure a witness observes the destruction of temporary paper files that contain personally identifiable information and protected health information.
Closure Date:
| ||||
| 25-02487-143 | Audit of Pharmaceutical Purchases Made Outside the Prime Vendor Contract | Audit | ||
1 Develop and establish guidance detailing how medical facility staff must document evidence to support their decisions when they make pharmaceutical purchases through the open market.
2 Ensure medical facility leaders conduct routine assessments of pharmaceutical purchases made through the open market so purchases are made in accordance with policy.
3 Develop a mechanism, in coordination with VHA’s purchase card program office and VA’s Office of General Counsel, that provides visibility into all pharmaceutical purchases, including purchases outside the prime vendor contract.
| ||||
| 25-04347-110 | Review of Physical Security of Information Technology Equipment at the Columbia, South Carolina, VA Regional Office | Review | ||
1 Update the local inventory procedure to include a process for securing information technology equipment when temporary space is needed and for tracking and distributing this equipment, in accordance with federal and VA requirements.
2 Assess the age of all unused information technology inventory to determine what should be used and what should be disposed of based on federal and VA requirements, and take action to address the results.
Total Monetary Impact of All Recommendations
Open: $305,607
Closed: $0
Total: $305,607
| ||||
| 25-00333-137 | Review of Primary Care Providers’ Completion of Electronic Health Record Documentation at the VA Augusta Health Care System in Georgia | Hotline Healthcare Inspection | ||
1 The Veterans Integrated Service Network 7 VA Southeast Network Director ensures relevant system staff and leaders are trained on state licensing board reporting requirements to include timeliness of reporting.
| ||||
| 25-00257-149 | Healthcare Facility Inspection of the VA Wilmington Healthcare System in Delaware | Healthcare Facility Inspection | ||
1 The Chief of Staff ensures facility leaders develop workflows for all services to identify team members’ roles in the process for communicating test results.
| ||||
15591