Recommendations
2060
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 23-00080-227 | Deficiencies in Facility Leaders’ Response to Critical Surgical Events at the Michael E. DeBakey VA Medical Center in Houston, Texas | Hotline Healthcare Inspection | ||
1 The Houston VA Medical Center Director ensures that staff conduct and document focused professional practice evaluations for cause as required by the Veterans Health Administration.
Closure Date:
2 The Houston VA Medical Center Director reviews processes for reporting providers to state licensing boards and the national practitioner data bank when a concern for patient safety is identified, and takes action to ensure compliance.
Closure Date:
3 The Houston VA Medical Center Director reviews the processes for conducting root cause analyses to ensure that reports are completed timely and that action plans are measurable, sustainable, and monitored to completion.
Closure Date:
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| 22-03247-198 | VHA Should Continue to Improve Water Safety and Oversight of Prevention Practices to Minimize the Effects of Legionella | Audit | ||
1 The assistant under secretary for health for support should establish certification procedures for Veterans Integrated Service Networks to ensure medical facilities’ healthcare-associated Legionella disease prevention plans for buildings comply with Veterans Health Administration Directive 1061 requirements.
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2 The assistant under secretary for health for support should develop and ensure Veterans Integrated Service Networks perform and document quality control and quality assurance checks of their requirements for oversight and enforcement of the Veterans Health Administration Directive 1061 quarterly Legionella water testing procedures conducted by the facility.
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3 The assistant under secretary for health for operations should monitor Veterans Integrated Service Network officials fulfillment of their oversight responsibilities found in Veterans Health Administration Directive 1061 regarding Legionella water sampling, testing, remediation efforts, and reporting of Legionella water testing data, including the post-remediation test results.
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4 The director of the Office of Healthcare Engineering should consider alternative measures, such as adding dedicated resources, to provide expertise and support for medical facilities experiencing persistent positive Legionella in facility water supply systems after applying the remediation efforts prescribed by Veterans Health Administration Directive 1061.
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5 The director of the Office of Healthcare Engineering should assist the Salem VA medical center with their persistent positive Legionella in the facility water supply system, and, with consideration of the ongoing water supply system renovations, develop an action plan to mitigate remediation challenges.
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6 The director of the Office of Healthcare Engineering should clarify the responsibility section of Veterans Health Administration Directive 1061 to clearly define oversight responsibilities for ensuring required remediation steps are completed when facilities received positive Legionella water test results.
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7 The director of the Office of Healthcare Engineering should revise the Water Safety Management Tool to alert Veterans Integrated Service Network and medical facility oversight officials when quarterly testing data is not posted.
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8 The assistant under secretary for health for operations should take actions to confirm that Veterans Integrated Service Network officials are ensuring front-line staff are routinely notified by responsible medical facility officials when elevated Legionella water sample levels require diagnostic awareness and additional clinical surveillance of veterans to detect Legionnaires’ disease.
Closure Date:
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| 22-00073-223 | Comprehensive Healthcare Inspection of the Alexandria VA Health Care System in Pineville, Louisiana | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs complete Focused Professional Practice Evaluations.
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2 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs consistently review Ongoing Professional Practice Evaluation data.
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3 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers with equivalent specialized training and similar privileges complete Ongoing Professional Practice Evaluations of licensed independent practitioners.
Closure Date:
4 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers complete the Comprehensive Suicide Risk Evaluation following a positive suicide risk screen and include an assessment of whether the current suicidal ideation was the most severe in the last 30 days.
Closure Date:
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| 22-00074-218 | Comprehensive Healthcare Inspection of the Gulf Coast Veterans Health Care System in Biloxi, Mississippi | Comprehensive Healthcare Inspection Program | ||
1 The System Director evaluates and determines any additional reasons for noncompliance and ensures leaders follow their defined governance structure.
Closure Date:
2 The Chief of Staff determines any additional reasons for noncompliance and ensures leaders use service-specific criteria in the Ongoing Professional Practice Evaluations of licensed independent practitioners.
Closure Date:
3 The Chief of Staff determines any additional reasons for noncompliance and ensures service chiefs maintain Ongoing Professional Practice Evaluation data in licensed independent practitioners’ privileging folders.
Closure Date:
4 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures practitioners with equivalent specialized training and similar privileges complete professional practice evaluations of licensed independent practitioners.
Closure Date:
5 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Executive Committee of the Medical Staff reviews the service chiefs’ recommendations along with clinical competence information when making privileging recommendations for licensed independent practitioners.
Closure Date:
6 The System Director determines any additional reasons for noncompliance and ensures staff maintain a clean and safe environment.
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| 22-00076-222 | Comprehensive Healthcare Inspection of the Central Arkansas Veterans Healthcare System in Little Rock | Comprehensive Healthcare Inspection Program | ||
1 The Director determines the reasons for noncompliance and ensures staff complete an individual root cause analysis for all patient safety events assigned an actual or potential safety assessment code score of 3.
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2 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs define time frames for Focused Professional Practice Evaluations.
Closure Date:
3 The Director evaluates and determines any additional reasons for noncompliance and ensures clinicians complete a Comprehensive Suicide Risk Evaluation following a positive suicide risk screen for patients seen in the Emergency Department.
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4 The Director evaluates and determines any additional reasons for noncompliance and ensures clinicians create or update a suicide safety plan for patients determined to be at intermediate, high-acute, or chronic risk-for-suicide and safe to discharge home from the Emergency Department.
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5 The Director evaluates and determines any additional reasons for noncompliance and ensures clinicians follow up within seven days with patients determined to be at intermediate, high-acute, or chronic risk-for-suicide who were discharged home from the Emergency Department.
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| 22-02800-225 | Delay in Diagnosis and Treatment for a Patient with a New Lung Mass at the Hampton VA Medical Center in Virginia | Hotline Healthcare Inspection | ||
1 The Hampton VA Medical Center Director assesses the current use of care coordination agreements between the Patient Aligned Care Team and specialty care services, and determines if there would be benefit in developing agreements where they do not currently exist.
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2 The Hampton VA Medical Center Director, in conjunction with the Radiology Department chief, reviews the Radiology Department standard operating procedures and scheduling processes, identifies deficiencies, and ensures compliance with Veterans Health Administration policies.
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3 The Hampton VA Medical Center Director, in conjunction with the Primary Care Service chief, reviews the Patient Aligned Care Team processes, identifies deficiencies, and ensures compliance with Veterans Health Administration Patient Aligned Care Team requirements, including scheduling huddles, follow-up of Emergency Department patient discharges, and communication with and coordination of specialty care.
Closure Date:
4 The Hampton VA Medical Center Director, in conjunction with the Primary Care Service chief, reviews the Patient Aligned Care Team pain management and referral processes, identifies deficiencies, and takes action as warranted.
Closure Date:
5 The Hampton VA Medical Center Director, in consultation with a subject matter expert from the National Program Office for Oncology, reviews the facility cancer registry program, identifies deficiencies, and ensures compliance with Veterans Health Administration requirements, including the need for a qualified cancer registrar and entry of all cancer cases in the registry.
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6 The Hampton VA Medical Center Director reviews the completed root cause analysis in order to ensure its completeness, and take action if warranted.
Closure Date:
7 The Hampton VA Medical Center Director reviews the institutional disclosure made to the patient’s family and completes any required items not addressed, including providing the patient’s family with information about potential compensation from the Veterans Benefits Administration and under the Federal Tort Claims Act.
Closure Date:
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| 22-02377-217 | Review of Veterans Health Administration’s Multi-Tiered Patient Safety Program | National Healthcare Review | ||
1 The Assistant Under Secretary for Health for Quality and Patient Safety establishes facility patient safety program oversight requirements for patient safety officers to include minimum frequency and volume of oversight activities and expectations for follow-up when patient safety program deficiencies are identified.
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2 The National Center for Patient Safety Executive Director evaluates the National Center for Patient Safety quarterly reports, includes an analysis of patient safety data in the reports, and establishes a mechanism for National Center for Patient Safety, in conjunction with Veteran Integrated Service Networks, to direct interventions to promote improvements when facility patient safety program requirements are not met or if deemed necessary to enhance patient safety programs.
Closure Date:
3 The Under Secretary for Health evaluates barriers to communication between third-party administrators and patient safety officers and takes action as needed to resolve barriers.
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4 The Assistant Under Secretary for Health for Quality and Patient Safety evaluates barriers that limit engagement between Veteran Integrated Service Network and facility directors and patient safety officers and patient safety managers.
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5 The National Center for Patient Safety Executive Director develops a patient safety program staffing configuration for patient safety managers to include facility complexity and patient safety program requirements with recurring reassessment and revision based on requirement changes.
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6 The National Center for Patient Safety Executive Director establishes staffing guidance for Veteran Integrated Service Network patient safety programs to include facility complexity and workload from other assigned responsibilities to ensure prioritization of patient safety officer oversight and support of facility patient safety programs.
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7 The National Center for Patient Safety Executive Director establishes processes to evaluate factors contributing to patient safety managers and patient safety officers’ burnout, including patient safety manager turnover, and implements actions as needed to address burnout.
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8 The National Center for Patient Safety Executive Director evaluates patient safety manager and patient safety officer training and implements standardized formalized training with requirements for newly appointed patient safety managers and newly appointed patient safety officers to include time frames and completion.
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9 The National Center for Patient Safety Executive Director establishes standardized continuing education requirements to meet the training needs for patient safety managers and patient safety officers.
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| 23-01138-203 | Inspection of Information Security at the VA Dublin Healthcare System in Georgia | Information Security Inspection | ||
1 Improve vulnerability management processes to ensure system changes occur within organization timelines.
Closure Date:
2 Develop and approve an authorization to operate for the special-purpose systems.
Closure Date:
3 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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4 Review the list of unauthorized software and remediate or remove unneeded software at the facility.
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5 Implement the appropriate physical security controls to restrict and monitor access to the facility, its server room, communication closets, and generators.
6 Implement and monitor emergency power and uninterruptible power supplies that support information technology resources.
Closure Date:
7 Validate that appropriate physical and environmental security measures are implemented and functioning as intended.
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| 22-03525-195 | VA Should Strengthen Enterprise Cloud Security and Privacy Controls | Audit | ||
1 The assistant secretary for information technology develop a timeline for updating the security and privacy guidance to reflect the latest revisions to the National Institute of Standards and Technology Special Publication 800-53, Security and Privacy Controls for Federal Information Systems and Organizations, and address identified weaknesses with personally identifiable information and supply chain management.
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2 The assistant secretary for information technology eEstablish a mechanism to ensure continuous monitoring of VA Enterprise Cloud systems to include having and testing contingency, incident response, and disaster recovery plans and conducting scanning as required.
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3 The assistant secretary for information and technology ensure VA Directive and Handbook 6517 are updated to reflect the revised National Institute of Standards and Technology requirements.
4 The assistant secretary for information and technology continue to improve criteria and processes for submitting claims for recoupment of service credits.
Closure Date:
5 The assistant secretary for information and technology assign roles and responsibilities for submitting claims for service credits and monitoring outcomes.
Closure Date:
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| 23-01179-204 | Inspection of Information Security at the VA El Paso Healthcare System in Texas | Information Security Inspection | ||
1 Implement a more effective vulnerability management program to address security deficiencies identified during the inspection.
Closure Date:
2 Ensure vulnerabilities are remediated within OIT’s established time frames.
3 Ensure that physical access for the data center and communication rooms are reviewed on a quarterly basis.
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4 Ensure physical access controls are implemented for communication rooms.
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5 Ensure a video surveillance system is operational and monitored for the data center.
6 Ensure communication rooms with infrastructure equipment have adequate environmental controls.
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7 Ensure water detection sensors are implemented in the data center.
8 Test the emergency power bypass during annual uninterruptible power supply testing and document results.
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14935